The purpose of the book

The reform of mental health services is now a prominent issue in most economically developed countries and also in several countries of Central and Eastern Europe.Although the speed and the precise local detail of these changes vary between countries, there is a clear need for an overall conceptual framework, which can assist both those leading and those who are affected by these changes. In a sense this book acts as a guide,providing a map of the territory and a compass to orientate the direction of reform.

The process of re-modelling mental health services is a reform in two senses: it is a profound change in the values informing how treatment and care should be provided to people suffering from mental illness, and it is also a radical structural change in the physical shape and pattern of services. This book seeks to provide an overall conceptual model, and acts as a pragmatic manual to help thos e who are involved in changing mental health services and those who wish to learn from evidence and experience accumulated elsewhere.

In this volume, we shall selectively present evidence for the clinical effectiveness of community-based mental health services, including the results of research studies, such as randomised controlled trials. We shall also include a range of other types of evidence, such as knowledge based on the experience which has accrued from good clinical practice, especially in those areas not yet subjected to formal evaluation.

The meaning of ‘community’

Health professionals are familiar with the importance of taking a clinical history so that a detailed appreciation of the past can lead to a richer interpretation of the present. The same ‘historical’ approach used to translate symptoms into diagnoses is applicable to the translation of words into useful concepts. In this manual, before discussing community mental health services we need to address at the outset the question: what is the meaning of ‘that overused word community’(Acheson,1985).

Table 2.1 shows five definitions of ‘community’,selected from the Concise Oxford Dictionary. The first two meanings (‘all the people living in a specific locality’, ‘a specific locality, including its inhabitants’), include both the people in a particular area and that locality itself. These lead us to our view that mental health services are often best organised for defined local areas, for all local residents, and that research upon such services will necessarily include consideration of the size and characteristics of the population at risk (the denominator).We shall return to what has been called ‘the science of the denominator’ when we discuss the ‘local level’ in Chapter 5 (Henderson,1988).

The third definition (‘body of people having a religion, a profession, etc., in common’) is consistent with our argument when we consider disaggregated sub-groups of the total population who may be at higher risk for particular mental disorders, or whose needs for services are distinct. Such groups may include immigrants, people who are homeless or those exposed to particular environmental or biological risk factors such as bereavement or pregnancy.

Overview of the historical development of mental health services in the Region

The countries in the Region differ in the degree to which they have been involved as territories and cultural settings in the emergence of Western Civilization. Whereas the countries of Central Europe such as Poland, the Czech Republic and Hungary have been fully integrated in the processes of carving human individuality out of a diffuse primitive group identity reaching back several centuries and variously referred to as capitalist development, scientific revolution or Renaissance, the countries further East or Southeast,such as Russia, Ukraine and the Balkan states have stayed peripheral to these concerns largely because of their own major preoccupation – the Eastern Orthodox Religion and the Ottoman Empire.The resemblance between these two groups of countries, revealed to the observer when the Berlin Wall fell, turned out to be more apparent than real and quickly wore out as soon as the regimes of total control were toppled and the peoples were free once again to get in touch with their own histories and cultural processes.

For reasons of simplicity the countries of the former Eastern block will be referred to throughout the chapter as ‘the Region’. The list of these countries will include the Newly Independent States (e.g. Russia, Ukraine, Belarus, Moldova), the countries of the Caucasus region (e.g. Georgia, Armenia, Azerbaijan), the countries of Central Asia (e.g. the KirghizRepublic), the Baltic countries, the Balkan countries (e.g. Bulgaria, Yugoslavia, Romania, Albania, Croatia, Macedonia, Bosnia and Herzegovina) and the countries of Central Europe.

The aim of this chapter is to complete the Part I of this book by providing the historical context for the development of community mental health services.Amore detailed description of the model follows in Parts II and III of the book. Following this, in Part IV we shall turn to the practical application of the model in the process of re-forming mental health services.

We present here only a highly selective account of the historical background for the following reasons. First, we are not historians and an extended historical appraisal is beyond our competence. Second, several excellent relevant historical analyses have now been published,to which we refer readers who seek more a detailed understanding (Jones, 1972; Scull, 1979; Levine, 1981; Gilman, 1996; Grob, 1991). Finally, we want to avoid the risk of being excessively absorbed by a contemplative appreciation of the past, at the expense of addressing the future.

The matrix model and the development of mental health care.

The matrix model can be used as one framework to help understand the historical development of mental health services over the last 150 years. Several different approaches have been used in analysing these trends.The main forms of historical analysis are: socio-economic, political and clinical/ technical. These approaches can all be placed (within the over-arching structure provided by the matrix model) in relation to three historical periods.

Period 1 describes the rise of the asylum between about 1880 and 1950; Period 2 is the decline of the asylum, from around 1950 to 1980; and Period 3 refers to the re-forming of mental health services, since approximately 1980.

Historical Overview

The end of the institutional era in psychiatry (the transition from Period 1 to Period 2 proposed by the authors of this book) arrived later in the USA than in northern Europe. While Britain, Norway and the Netherlands were experimenting successfully with the therapeutic community, open-door hospitals, early discharge, and other forms of institutional reform in the early 1950s, in the USA people with psychosis generally were still locked away in archaic asylums. Only after the antipsychotic drugs and Medicaid health insurance for the indigent were introduced in the middle of the 1950s did deinstitutionalisation take off in America, and, even then, it was primarily effected by transferring people with psychotic illness from hospital to such ‘community’ facilities as nursing homes and massive boarding homes where treatment was often inadequate or non-existent (Warner, 1994).

Medicaid is a health insurance programme funded jointly by the federal and state governments which covers treatment of recipients with mental illness in the community but not in free-standing psychiatric hospitals. State hospitals, are entirely supported by the state budget. This arrangement created an unusual fiscal incentive for state governments to transfer patients out of state hospitals to access federal funding, and promoted radical deinstitutionalisation policies. The elimination of public psychiatric beds, after the advent of Medicaid, progressed further and faster in the USA than anywhere else in the world at that time.

Defining the input phase

We define as inputs ‘the resources which are put into the mental health care system’

Defined in this way, inputs are those elements which are injected into the total mental health service system, and which need to be distinguished from the activities which take place within that system in providing mental health care,which we describe in the next chapter as the process phase.These resources enter the system at the three geographical levels, and may be further categorised as visible or invisible.

The visible inputs consist mainly of staff and facilities. In psychiatry, as compared with other medical specialities, a relatively small contribution towards visible inputs at present is expenditure on medication, supplies, equipment and investigations. Visible expenditure on staff includes the numbers, the mix of different disciplines (such as psychiatrists, psychologists and nurses) and their relative distribution across the service as a whole.

Often forgotten are the invisible inputs which activate the visible system inputs, and which potentiate the effective functioning of the service network.Without these invisible factors the visible inputs may be rendered largely ineffective. Indeed, the influence of these invisible inputs usually only becomes manifest when they are absent, unrecognised or disregarded. One example is the importance of establishing good working relationships between specialist and general health services, and between health and social services, for the joint care of people with long-term and severe mental illness.

Defining the outcome phase

Outcome is defined in the Concise Oxford Dictionary as ‘a result, a visible effect’. This sense that an outcome is the final step of a sequence of events is reinforced by the synonyms given for outcome in the Oxford Thesaurus, as shown in Table 9.1.

Outcomes are generally considered to be changes in functioning, in morbidity or in mortality (Thornicroft & Tansella, 1996). These outcomes are attributable to the treatment and care received, which themselves can be analysed as input and process variables. Outcomes are therefore a complex product of multiple influences, and they can be considered at the three geographical levels of the matrix model (Figure 9.1 shows such possible outcomes). The difficulties associated with defining and collecting outcomes data have meant that input and process variables have often been used as proxies for outcomes, a categorical error (Jenkins et al., 1994).

Outcome can be considered from two points of view.The first is the broad definition, which refers to changes in any variable, for example a politician may describe an increase in investment in mental health services (input) as a favourable outcome. Similarly, a service re-reorganisation, following a monitoring exercise, may lead to an increase in the average frequency of out-patient contacts with patients (process), which the patients and clinicians may see as a positive outcome.Second, the narrow definition refers only to the health status of an individual patient, or of aggregations of individual patient data, and implies measures taken at least at two time points, before and after a clinical intervention. In this chapter we shall deal with ‘outcome’ in terms of the second, narrow definition.

The purpose of the matrix model

In describing the matrix model in this book we have four aims: (i) to provide a framework which simplifies the description of mental health services, (ii) to offer a way to order complex events, which can happen at different times, as well as concurrently, (iii) to assist understanding of these events, and (iv) to help to identify service deficits and to prioritise actions for service improvement.

First, we have attempted to simplify a description of the structure and functions of mental health services, because their complexity often prevents comparative assessments, and may mean that those involved in providing or receiving services do not have a shared terminology with which to communicate.We are aware that simplicity, while it encourages the initial appeal of the model, is bought at the expense of specificity. On the other hand, this question of balance is one that needs to be answered in any theoretical model that seeks to represent complex reality.

Second, with the matrix model we have sought to bring order by choosing time and space as the classical Cartesian axes for our two-dimensional model. We have selected these dimensions because, in our view, they are largely independent and because their interactions offer the richest array of domains useful to reflect the astonishing degree of variability in actual mental health services.

This model is therefore intended as an integrative tool. This is especially fit for its purpose within mental health services as they are characterised by several processes that tend to produce disintegration. The variety of agencies and organisations involved will often produce fission not fusion.