Emerald Group Publishing Limited
Article Type: Editorial From: Mental Health and Social Inclusion, Volume 19, Issue 1
Social isolation and the demise of community mental health teams
Whether they retain their old “Community Mental Health Team” (CMHT) label, or have taken on a new nomenclature like “Recovery Teams”, our community mental health services and those whom they serve are facing something of a crisis. Cost improvements and the need to produce “cash releasing savings” mean that staff numbers have been cut and staff find themselves continually “fire-fighting” – reacting to problems and crises – rather than providing the recovery-focused support that might reduce the likelihood of such crises occurring.
As a result, thousands of people up and down the country are being discharged to primary care. Most have more serious mental health conditions but are considered “clinically stable”. It is therefore entirely appropriate that their clinical needs be met in primary care. Indeed, if the primary focus of clinical treatment is the General Practice then there is, in theory, the possibility of integrating physical and mental health care and improving the physical health of those facing mental health challenges (Department of Health, 2009). However, it ignores the critically important issue that community mental health services offer a great deal more than “clinical care” and have typically come to occupy a central place within people's lives.
Loneliness and isolation
Most people get stuck in community mental health services because they are lonely and isolated. Unlike their forbears who inhabited the remote institutions of yesteryear, they may be living in “the community” but they are rarely an active part of our communities and lack that sense of belonging that is so important for us all. For a few, relief from social isolation may have been found at the local day centre, but many of these have been closed. Too many have little to do other than staring at the TV and waiting for the weekly, fortnightly, or now more often monthly, visit from a care co-ordinator interspersed with a quarterly or biannual trip to a 15-minute psychiatric outpatient appointment. These constitute the only real social contact for too many people. Two decades ago, Ford et al. (1994) found that 40 per cent of people with ongoing mental health conditions living in the community had no social contacts outside mental health services. Almost 20 years later, those with mental health conditions remain the most socially isolated of all disabled people (Office for Disability Issues, 2013). Evaluation of the “Time to Change” anti-stigma programme in England shows that half of those surveyed report being shunned by others and that negative discrimination is most commonly reported from friends, family and social life (Corker et al., 2013).
Social isolation is not only bad for mental health (Harvey and Brophy, 2011) it is also very bad for physical health. Indeed, Holt-Lunstad et al. (2010) in their meta-analysis of research papers showed that social isolation increases risk of death more than obesity, or inactivity or drinking:
Data across 308,849 individuals, followed for an average of 7.5 years, indicate that individuals with adequate social relationships have a 50% greater likelihood of survival compared to those with poor or insufficient social relationships. The magnitude of this effect is comparable with quitting smoking and it exceeds many well-known risk factors for mortality (e.g. obesity, physical, inactivity) […]. Physicians, health professionals, educators, and the public media take risk factors such as smoking, diet, and exercise seriously; the data presented here make a compelling case for social relationship factors to be added to that list (Holt-Lunstad et al., 2010, p. 14).
Now, for large numbers of people, that meagre social contact afforded by of the community mental health service is being removed. Primary care simply cannot offer the regular home visits to lonely, isolated people to replace those of the CMHT/Recovery Team. As one person said to us “They make mental health services become your life and then they get rid of them”.
It is not only the last vestiges of social contact that people lose when they are discharged from CMHTs. Community services have historically provided people, through their care co-ordinator, with help to navigate the complexities of everyday life and access the generic services they need: housing, medical, welfare benefits, education, employment, etc. This assistance is lost on discharge. Use of secondary mental health services can also be a passport to other important things such as concessionary travel, and even eligibility for social care.
The need for real alternatives
In times like these, it is tempting to argue against cuts in community services. If people simply remain in community mental health services all problems will be solved. As Judi Chamberlin (1977/1988) has argued, when times are hard it is tempting to call for “[…] more experts and more of their services, unable to acknowledge that it is the system itself that is the problem” (p. xiv). It is undeniable that some people have found help within the mental health system, but “Needles have been found in haystacks too, but this does not recommend haystacks as a good place to store needles. Patients who find help do so in spite of the structure of the mental health system, not because of it […]” (Chamberlin, 1977/1988, p. xiv).
The social contact afforded by community mental health services has not prevented social isolation or enabled people to become part of our communities. Few of us would describe a fortnightly visit from a CPN and a quarterly appointment with a psychiatrist as an adequate social network and, to add insult to injury, the people offering these change regularly (staff rotate, move on, get promoted, retire; services are reorganised) so even this meagre human contact does not offer a stable relationship. Although day centres offered social contact, this remained in segregated settings – people were not part of our communities – and the social contact offered was on staff terms. The service decided who could attend and determined for how long they could do so: rarely could people continue to attend the day centre indefinitely. The theory was that people would move on to mainstream opportunities, the reality was that they often moved on to nothing. It was the social contact afforded by day centres that attendees most valued about day centres (Faulkner, 2000), yet it was their therapeutic value that was emphasised by staff. People were rarely allowed simply to drop in and visit friends, they were required to attend a therapeutic group programme: failure to do this would not infrequently mean the person was discharged as unsuitable. It was not uncommon for social contact among attendees outside the “therapeutic milieu” of the centre to be discouraged.
In an age of ever decreasing public sector funding, it should also be noted that community mental health services staffed by professionals are an expensive way of offering the meagre social networks and intermittent support that they have afforded. If social isolation, lack of social networks, and the need for support to navigate day–to-day life, are primary problems, then do we really need expensive mental health professionals to provide them? Might there not be others better placed to help people to rebuild their lives and networks – probably those who have faced similar challenges themselves?
We would suggest that the point has been reached where we cannot just keep slicing bits off existing, highly professionalised, models of service and we would question whether we would want to even if we could. Maybe the crisis we are facing offers opportunities for exploring genuine alternatives. As Judi Chamberlin (1977/1988), and more recently Mary O’Hagan (2014) have argued, the creation of alternatives “is not a job that can be turned over to experts […] It is a task that must be done by all of us, working together” (Chamberlin, 1977/1988, p. 14). The real alternatives lie not in more experts or the alternative prescriptions of “radical professionals bent on liberating us from the structures and strictures of traditional psychiatric services” but in “patient controlled services […] in which all the basic decision making power is in the hands of those the facility exists to serve’” (Chamberlin, 1977/1988, p. 113):
People with mental health problems, as well as communities, need to start believing they hold most of the solutions to human problems instead of professionals and services […] [the mental health system] needs to hand over control to service users and communities, through fostering service-user leadership in recovery and in services, integrating with other sectors and engaging in community development and social inclusion work(O’Hagan, 2007, p. 5).
The quest for real alternatives
Over the last year, we have tried to include in the pages of Mental Health and Social Inclusion some peer-controlled alternatives and examples that integrate with other organisations within communities. For example, Recovery Rocks in Western Australia (Waegeli, 2014) and Prosper in southwest London (Barrett et al., 2014) provide excellent examples not of “services”, but of communities of between 100 and 200 people who have experienced mental health challenges. They aim to enable people to use and strengthen their abilities to transform their lives, those of others facing similar challenges and the communities in which they live. Such communities recognise the power of peer support in the journey of recovery and are based on reciprocity: there is the expectation that each member will give what they can, when they can, to the community and in doing so receive what they need, when they need it, back from the community.
In Liverpool, Mather (2014) describes using the rich pool of talent among people using services to transform day services based on peer support; and the Recovery Colleges described by Meddings et al. (2014) and McCaig et al. (2014) offer a different way of enabling people to discover their potential and explore their possibilities based on self-determination and peer support. If they are opened up to anyone in our communities who needs them they also offer the possibility of enabling those who use mental health services and those who do not to come together on equal terms, thus breaking down boundaries between “them” and “us”, increasing the capacity of communities to accommodate people with mental health conditions, and offering support for anyone experiencing mental distress.
Examples in the current issue include Creative Minds (Walters, 2015), and Real Lives (Perkins et al., 2015). Creative Minds in southwest Yorkshire develops partnerships between Trust staff, people using mental health services and community organisations for local people. The 130 creative projects in 95 voluntary, third sector, not-for-profit and community organisations offer creative, spiritual, sporting and environmental opportunities to over 3,000 people. Real Lives in Nottingham (Perkins et al., 2015) combines the power of peer support with personal budgets and self-directed support to put people receiving support in the driving seat of their own recovery journeys.
We would welcome papers from others who are developing genuine alternatives that put people in the driving seat of their lives. Alternatives that use the resources and resourcefulness of people with lived experience and communities to create ways of reducing disabling loneliness and isolation, enabling people to develop circles of friends and participate as equal members of our communities. Such genuine alternatives are necessary not only for those discharged from community mental health services, but also those who no longer enter their care: as mental health services in primary care can offer therapy and treatment to people who would have historically been referred to secondary mental health services, fewer people enter such services. While primary care may be able to meet their clinical needs, many will remain isolated and need resources and communities to help them develop social networks to regain and sustain their mental health and well-being.
To date these initiatives are relatively small scale in comparison with the tens of thousands of people hitherto served by community mental health services. Some might ask whether their size can be increased so that they can include all who may need them: both those leaving secondary mental health services and those who are no longer taken on by them. However, perhaps it is the sheer size of statutory services and larger non-statutory organisations that stifles the creativity and flexibility necessary for genuine personalisation and self-directed support. The more important question may not be whether the alternatives are scalable, but whether they can be replicated in different ways in different communities for different individuals and groups who may value them.
Questions must also be asked about the future role of CMHTs/Recovery Teams themselves. Perhaps they should simply provide access to specialist assessment, treatment and therapy? Perhaps social support and care co-ordination/support to navigate day-to-day life and the choices available should move outside statutory services? This would mean that people would not lose such assistance when they become “clinically stable” and are discharged. Maybe, for those who need them, “personal navigators” might replace “care co-ordinators” to provide help in day to day living and accessing supports and services (including mental health services) that they may need?
Rachel Perkins and Julie Repper
Barrett, D., Benson, J., Foster, R. and Leader, A. (2014), “Prosper: a social movement approach to mental health”, Mental Health and Social Inclusion, Vol. 18 No. 4, pp. 188-97
Chamberlin, J. (1977/1988), On Our Own, Mind Publications, London
Corker, E., Hamilton, S., Henderson, C., Weeks, C., Pinfold, V., Rose, D., Williams, P., Flach, C., Gill, V., Lewis-Holmes, E. and Thornicroft, G. (2013), “Experiences of discrimination among people using mental health services in England 2008-2011”, British Journal of Psychiatry, Vol. 202 No. 55, pp. 48-63
Department of Health (2009), New Horizons, A Shared Vision for Mental Health, HM Government, London
Faulkner, A. (2000), Strategies for Living: A Report of User-Led Research into People's Strategies for Living with Mental Distress, Mental Health Foundation, London
Harvey, C. and Brophy, L. (2011), “Social isolation in people with mental illness”, Medicine Today, Vol. 12 No. 10, pp. 73-78
Holt-Lunstad, J., Smith, T.B. and Layton, J.B. (2010), “Social relationships and mortality risk: a meta-analytic review”, PLoS Med, Vol. 7 No. 7, p. e1000316
McCaig, M., McNay, L., Marland, G., Bradstreet, S. and Campbell, J. (2014), “Establishing a recovery college in a Scottish University”, Mental Health and Social Inclusion, Vol. 18 No. 2, pp. 92-7
Mather, E. (2014), “The benefits of peer support: transforming day services in hard times”, Mental Health and Social Inclusion, Vol. 18 No. 3, pp. 151-4
Meddings, S., Guglietti, S., Lambe, H. and Byrne, D. (2014), “Student perspectives: recovery college experience”, Mental Health and Social Inclusion, Vol. 18 No. 3, pp. 142-50
Office for Disability Issues (2013), Fulfilling Potential. Building a deeper Understanding of Disability in the UK Today, Department for Work and Pensions, London
O'Hagan, M. (2007), “Parting thoughts”, Mental Notes (Mental Health Commission, Wellington, New Zealand), 18, pp. 4-5
O'Hagan, M. (2014), Madness Made Me, Open Box Publishing, Wellington, NZ
Perkins, R., Atkins, J., Hunter, N., Repper, P., Robertson, P., Thornton, P. and Thornton, S. (2015), “Real lives: promoting recovery through personalisation and peer support”, Mental Health and Social Inclusion, Vol. 19 No. 1, pp. 22-9
RFord, R., Beadsmore, A., Norton, P., Cooke, A., and Repper, J. (1993), “Developing case management for the long-term mentally ill”, Psychiatric Bulletin of the Royal College of Psychiatry, Vol. 17 No. 7, pp. 409-11
Waegeli, A. (2014), “The recovery rocks community story”, Mental Health and Social Inclusion, Vol. 18 No. 2, pp. 61-7
Walters, P. (2015), “Creative minds: developing supportive creative opportunities within our communities”, Mental Health and Social Inclusion, Vol. 19 No. 1, pp. 30-7