This chapter introduces the community as a context for work with severe and enduring mental health problems, identifying how ill-health is defined and exploring the drivers that shape community mental health services. The approaches used by these services are explained as a basis for understanding teamwork. There is a section on medication, which is important for many people with severe and enduring mental health problems. In the UK, community mental health now encompasses many different service settings, raising an issue about how the required generic skills could overshadow the specific use of occupational therapy for recovery and support.

From a global perspective, challenges for people with mental health problems are primarily concerned with access to services and reduced life expectancy, often associated with stigma within and beyond health services. The majority of people receive no treatment (WHO 2008). Life expectancy is reduced by up to 20 years for men and 15 years for women. Factors contributing to this include issues such as suicides and accidents producing higher rates of unnatural deaths. Smoking and use of other substances contribute to physical health problems which reduce life expectancy (Wahlbeck et al. 2011). The UN (2006) has promoted the Convention on the Rights of Persons with Disabilities, emphasizing the role of social policy, health promotion, illness prevention and care provision in tackling health inequalities.

Severe and Enduring Mental Health Problems

Diagnosis is often a requirement for access to mental health services. The two main frameworks that are used to define and identify mental health problems are the World Health Organization’s International Classification of Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V). There are similarities between the two systems, which focus on symptoms to aid diagnostic reasoning and categorization. A survey by Mezzich (2002) of psychiatrists across 66 countries identified that the ICDH-10 system was preferred for clinical use, while the DSM-IV-TR was used more often in research.

For a wider audience, Rethink (2008) lists common features of definitions for people with severe and enduring mental ill-health as:

■ They are diagnosed primarily with a mental health condition, typically schizophrenia or a severe affective (mood) disorder

■ They experience substantial disability affecting their capacity to care for themselves independently, sustain relationships or commit to voluntary or paid employment

■ They are currently displaying florid symptoms or experience mental health problems for prolonged periods of time

■ They have experienced recurring crises, leading to frequent hospital admissions or interventions and/or receive significant and ongoing support from their informal carers

■ They occasion significant risk to their own health or safety or to that of others.

These are common components between different diagnoses and definitions of severe and enduring mental ill-health, indicating the major impact on potentially all aspects of an individual’s life at some point (Rethink 2008). The impact on their level of functioning means that people often require ongoing contact with services. Enabling them to overcome difficulties in coping with daily living occupations such as work or household chores is important, recognizing a person’s potential for recovery and self-management.

Occupational therapy offers a valuable means for people to address these difficulties, working at levels of skills, tasks, activities and occupations (see Ch. 3). Occupation is used to address thinking, practical and organizational skills. Thinking skills include problem-solving, instilling hope, improving motivation, developing meaning and building confidence. Specific practical skills are wherever possible, negotiated collaboratively with the individual. Examples include budgeting, shopping, cooking, getting out and about, using public transport and using community facilities. Organizational skills such as balancing activities, structuring the day, establishing routines and making good use of time can also be promoted. These different areas of practice are supported by the drivers which shape community mental health services.

Drivers

Community mental health services are shaped by local, national and international policy-makers. In contrast to institutional settings, the World Health Organization (WHO 2007) considers community mental health services to be more accessible and effective. By reducing social exclusion caused by institutional care, there is less potential for neglect and violation of individual rights. In the UK, community care has generally been linked with greater satisfaction from service users and improved quality of life (Killaspy 2006). However, issues remain. It is not necessarily cheaper than hospital-based care. There are also concerns that new, smaller institutions have been created where the potential for harmful institutional practices remain. To guard against such practices, which favour the smooth working of the institution over individual rights, essential elements of good community care have been highlighted, including the provision of effective and accessible services that are highly individualized (van Weeghel et al. 2005).

Community care has not eliminated social exclusion, which is associated with inequality and the concentration of ill-health in poor and marginalized groups and communities (Godlee 2012). Policies to promote social inclusion have indicated the need to address the underlying social and economic causes (National Social Inclusion Programme 2008). However, challenges have arisen from reduced opportunities and resources for participation, caused by austerity measures.

These challenges, along with emerging evidence for effective interventions and approaches, constantly change the social, political and economic landscape. The occupational needs of individuals and communities can be championed by occupational therapists who are aware of this changing landscape and involved in shaping services. Regardless of the actual composition of services, priorities for delivering these services have to be agreed. Current priorities include ensuring that there is value for money, by focusing on the activities and interventions that are known to be effective. This has fostered processes for regulation and accountability at multiple levels, from individual professional accountability to an organizational and sector provider level (see Ch. 7).

Including service users in service evaluation gives voice to their expectations, stimulating current trends to include more personalized services with an emphasis on continued wellbeing and recovery. Accessible services require increasing use of digital media to communicate, assess, intervene and evaluate. Innovative practice involves developing entrepreneurship and understanding change management (see Ch. 8). The community setting offers many opportunities to demonstrate the importance and effectiveness of occupational therapy for people with severe and enduring mental health problems. The core principles can be aligned with specific supporting models and approaches such as recovery-oriented practice, a strength-based approach, the transtheoretical model of behavioural change and the stress vulnerability model.

SUPPORTING MODELS AND APPROACHES

Recovery-Orientated Practice

Recovery is a central theme in mental health and is covered more broadly elsewhere in this book. The focus for this chapter is on issues relevant to people with severe and enduring mental health problems.

In the UK, the shift to recovery-oriented practice was initially signalled in policy in 2001 (Department of Health 2001a), emphasizing that services would be as focused on recovery as they were previously on symptoms and illness:

The mental health system must support people in settings of their own choosing, enable access to community resources including housing, education, work, friendships – or whatever they think is critical to their own recovery.

(Department of Health 2001a, p. 24)

Three tasks of recovery have been identified by Slade (2009): developing a positive identity, self-management and developing valued social roles. From an occupational perspective, this is congruent with developing meaning and purpose from occupation in real-world settings, while seeing oneself as more than just a diagnosis. In the long term, for an individual a stance of hope and optimism is necessary. People may not have this stance of hope at points of their journey through services. At these times, the hope of the occupational therapist may sustain them. The evidence suggests that for people with a diagnosis of schizophrenia, 20–25% of people experienced complete recovery and 40–45% achieved social recovery (Warner 1994). These rates were generally stable across the decades, regardless of developments in drug treatments. Complete recovery is considered to be the absence of symptoms and a return to the level of functioning prior to diagnosis.

However, there are significant differences in recovery rates between developed and developing countries (Dorrer 2006). Developing countries have reported superior outcomes although the exact reasons for this are not established. Different conditions may have different courses of recovery. Recovery from enduring depression for some individuals is a slower process over time than for broadly similar groups of people with a diagnosis of schizophrenia (Dorrer 2006).

The importance of medication as part of enabling recovery has been highlighted (Turton et al. 2010). The management of symptoms has been consistently ranked as an important priority for service users and carers, alongside the desire to see the development of new innovative drug treatments. In addition, there has also been an emphasis on focusing on strengths, and the value of structure and routine through the use of meaningful activities.

Strengths-Based Approach

Statutory services have tended to be typically focused on providing care based on solving problems. A person is asked to identify their problem or multiple problems. Time is then spent with the person trying to improve such areas where they are experiencing deficits. To focus on deficits can act as a regular reminder of the problems or difficulties that are experienced. The strengths-based approach encourages a focus on a person’s strengths: what is the person good at? What have they achieved in their lifetime? What does the person get most out of in their life? What do they want most in their life right now? The principles of the strengths approach appropriate to UK practice have been documented by Ryan and Morgan (2004), who view the service user as the director of the process. They place strong emphasis on the use of community and neighbourhood services as resources for integration, rather than focusing solely on mental health resources, making this approach compatible with recovery-oriented practice and promoting social inclusion.

Cycle of Change

An understanding of the cycle of change can support collaboration and the use of relevant approaches that engender positive change, such as the transtheoretical model of behavioural change (Prochaska and DiClemente 1986). This model describes stages of change, starting with the present and identifying appropriate approaches and interventions towards the maintenance of healthier behaviour. People may progress incrementally through the stages or move backwards (relapse) or forwards (recovery), including jumping between the six stages.

Pre-Contemplation

At this stage, the person is not ready to change. Their lack of readiness to change is validated. An evaluation of the individual’s current behaviour is encouraged, while clarifying that any decision to change is theirs. An educational approach may be used to explore and personalize the risks and benefits of current behaviour.

Contemplation

The person is getting ready to change. Exploration of the pros and cons of behavioural change is encouraged and the recognition that ambivalence regarding change can delay action. The individual’s current perspective continues to be validated, while reinforcing that the choice to change is theirs. The exploration of potential and positive outcomes from changes in behaviour is promoted.

Preparation

The person is ready to change. An incremental graded approach is used to define appropriate challenges. Potential obstacles are identified and a problem-solving approach used to explore possible solutions. Social support networks are involved where possible to support and encourage the planned behaviour change. Skill acquisition may be necessary at this stage to enable the individual to change previous behaviours.

Action

The person has started to make changes to their behaviour. Newly acquired skills may be consolidated into habits and routines. Consistency and persistence are encouraged and minor setbacks dealt with. Feelings of loss for previous lifestyle or friendship groups may be present; therefore, the long-term benefits and rewards for current behaviour are reinforced.

Maintenance

The person has continued with the planned behavioural change. Progression to greater self-efficacy is emphasized. Dealing with stressful situations and potential relapse is explored, to reinforce coping strategies and identify support mechanisms, including emergency or crisis contacts.

Relapse

The person may return to previous behaviours. This may occur at any point. The setback needs to be validated, while recognizing that change can still occur, with the potential for new learning from the experience. The triggers for relapse can be explored while reassessing the stage of readiness to progress again. Coping strategies and support networks can be revisited and strengthened where necessary.

The cycle of change is particularly relevant for community practice and its use can support the delivery of appropriate person-centred occupational therapy. Jointly agreed interventions can engender change and develop understanding of the individual’s situation. This understanding can be used from the perspective of stress and vulnerability, which is now discussed.

Stress Vulnerability

The stress vulnerability model of schizophrenia described by Zubin and Spring (1977) sees individuals as having a predisposition or vulnerability to developing psychosis. Individual exposure to stress may trigger psychotic experiences. This simple model shows that more vulnerable people may need fewer stressors to develop a psychotic reaction. In contrast, less vulnerable people may need more stressors to develop psychosis. This model describes psychosis as being on a continuum, challenging stigma by suggesting that anyone could develop schizophrenia given enough stressors in relation to their own vulnerability.

Interventions may therefore be targeted at reducing stress or vulnerability. Working with the person on activities that they find relaxing can reduce personal levels of stress. Environmental stressors may be addressed directly, through changes to that environment or indirectly by removal to other less stressful environments. Vulnerability can be reduced by developing problem-solving skills, coping skills, social skills and support networks.

The stress vulnerability model incorporates biological, as well as psychological and social elements, by considering the effects of stress on physiology. As a biopsychosocial approach (Zubin and Spring 1977), it is relevant to all health professionals, enabling them to work together in teams. However, if the focus of this approach is on minimizing or avoiding stress it may lead to risk-averse practice, fostering low expectations of what individuals can achieve and undermining recovery-oriented practice and positive risk management (see also Ch. 11).

TEAM WORKING AND COORDINATED CARE

Team working is essential in providing a comprehensive and coordinated approach to the provision of mental health services. With the expansion of community care, policies such as the Care Programme Approach (CPA) (Department of Health 2008) have developed to ensure this provision is approached consistently for all.

The Care Programme Approach

The Care Programme Approach (CPA) (Department of Health 2008) was introduced in England in 1991 and reviewed in 2008 by the Department of Health. This approach continues to be central in organizing the delivery of care to those people who access secondary mental health services in the NHS. It is an integrated approach across health and social care services, promoting a coordinated approach within individual care packages. All services and resources are required to work together to provide the optimum level of care.

The aim of the CPA is to empower the person as the central concern, by considering all relevant aspects of their lives. It is for people with complex needs who require services from a number of agencies and/or professionals, because of the greater risk associated with their mental health problems. It is based on a whole systems approach, led by a care coordinator (Department of Health 2008). The CPA includes:

■ comprehensive assessment of needs

■ consideration and planning of all available resources to meet these needs

■ regular assessment and review of risk issues and management plans.

It should also involve people who have a caring role, including them so that their needs can also be assessed and met where possible. This helps clarify expectations about roles and responsibilities, setting boundaries for individuals and agencies involved. Occupational therapists are included in the range of professionals that may be involved and are often care coordinators.

The Care Coordinator

The CPA requires that all individuals have a care coordinator, an identified professional who aims for a strong, sustainable and hope-inspiring professional relationship with the service user (Repper and Perkins 2003). To empower the person and emphasize their expertise on their own experiences, it is important that the care coordinator focuses on strengths and needs and is not distracted by the agendas and priorities of others involved. The agreed care plan should be specific to the individual.

For anyone with severe and enduring mental health problems it is important that regular reviews take place. Within the CPA, the care coordinator is responsible for ensuring that an individual’s care plan is reviewed on a regular basis and that goals are specific, measurable, achievable, realistic and timely (SMART). Care plans are altered accordingly by the coordinator following agreement at each review. The care coordinator is not necessarily responsible for providing care but monitors that others are providing appropriate and timely care as agreed.

The role of the care coordinator is clearly defined by the CPA policy (Department of Health 2008) and is not profession specific. The process for identifying care coordinators for service users varies across teams, considering:

■ the needs of the service user

■ caseload sizes

■ complexity of the case

■ staff skills.

Care coordination should not take away from each individual profession’s ability to provide more specific intervention plans, but raises issues about the tension between generic and profession-specific working.

Care coordination does require consideration of problems with symptoms, medication, housing, legal issues and risks. Discussing these issues could be negative if a good therapeutic relationship has not been formed. Occupational therapists are well equipped to establish a good therapeutic relationship, based on appreciating the person’s strengths as part of an occupational journey to recovery (Kelly et al. 2010). However, often there are barriers to recovery due to lack of resources such as funding, opportunities, education and peer support. Overcoming these barriers requires creative thinking, to use occupational therapy specialist skills to support people effectively (see also Ch. 11).

Generic Versus Specialist Working

To provide specialist occupational therapy services, occupational therapists must spend the majority of their time using assessments and interventions that are occupationally focused (College of Occupational Therapists 2006). In contrast, generic work is defined as an activity that could be carried out by any profession or team member. Care coordination is often identified as generic work. However, as already identified, being a care coordinator does not necessarily mean providing services to a person, but coordinating their delivery. Profession-specific interventions can be provided alongside other elements of care. When working in teams and identifying appropriate care coordinators, people with greater occupational needs could be allocated to an occupational therapist for care coordination.

Another consideration is of the enhancements to a service user’s care when there is an occupational therapist as care coordinator. For example, securing appropriate housing may be viewed as a generic task for care coordination. Often housing is something that needs addressing, as it is the key environment for recovery and enabling occupation in everyday life. From an occupational perspective, securing accommodation could be an occupation that the person needs to do. The occupational therapist as care coordinator can support and enable the person in this occupation. This is particularly important if the individual is to be empowered and able to recover the most fulfilling and best quality of life. Practically, the occupational therapist could work jointly on completing forms, enabling the person to feel part of the process and to take ownership of their achievement at each stage. Meeting a basic need such as accommodation can ultimately promote a sense of belonging.

Partnership Working

Partnership working has been defined in healthcare policy at every level of practice (see Ch. 8). Fundamental to this is the partnership between mental health workers and users of mental health services, as well as family and carers. Tait and Shah (2007) also highlight the benefits of non-statutory organizations being involved in partnership working. These organizations enhance statutory services through advocacy and campaigning roles. They focus on practical help with housing, welfare and financial advice. Social exclusion can be addressed with local services providing opportunities for work, training, leisure and social contact. Non-statutory services are sometimes more able to engage with people who distrust statutory services, being responsive to their needs but not associated with compulsory detention and treatment (see Chs 22 and 27).

For effective partnership working, there needs to be a clear understanding of what different services provide, where there is an overlap of provision and what the unique aspects of a service are. Services need to be coordinated, with timely signposting so that people can make informed decisions to meet their needs and navigate their way around the multiple agencies.

Risk

Risk has implications for all areas of practice. The level of risk is constantly changing and often cannot be eliminated. Empowering people to make their own choices and decisions requires consideration of risks. With thorough assessment and good management risk can be minimized. When the media focus on violent incidents, especially in the community setting, they are quick to blame public services such as health and social care, which may have been involved (Anderson 2003). All practitioners must ensure decisions are defensible through gathering as much information as possible and making clear, reasoned, action plans. There are formal processes for clinical risk assessment and for people working alone. The community setting involves working in varied venues, requiring ongoing risk assessment, but there should always be positive risk management to balance avoidance with opportunities.

Clinical Risk Assessment

All members of multidisciplinary teams are responsible for contributing to the clinical risk assessment of a person. Clinical risk assessment takes place throughout the person’s journey within mental health services (see Ch. 5). Workplaces will have local policies regarding risk and these must always be consulted for guidance when completing documents. In the UK, the Care Programme Approach (Department of Health 2008) ensures that detailed risk assessments are carried out regularly in a person’s care.

Lone Working

Community working often means lone working. All employers and organizations should provide a lone working policy. While visiting people in their own homes a number of safety issues should be considered including:

■ Does the person live alone or are there others in the house?

■ How well is the person known to the service?

■ Does any member of the household pose any known risks to others?

■ Is the surrounding area safe or is there potential risk posed by others in the area?

If any of the above is a concern, then action must be taken accordingly and in-line with any relevant organizational policies. Considerations might include:

■ A visit with two staff present

■ Ensure a system is in place at base for notifying others of whereabouts and expected time of return

■ Use mobile phones to inform others at base, of time of arrival and of leaving property

■ Use other agencies, such as police, for support

■ Identify an alternative safe place to see the person.

Additional considerations should also include:

■ Are there animals in the household and is the owner able to keep them under control for the duration of the visit?

■ Do people smoke within the household and are they able to abstain during the duration of the visit?

Sometimes if staff are concerned regarding visiting a particular household, then they will try to get in and out of the house as quickly as possible. This does not provide the person with the optimum level of service and places staff at risk, therefore, if there is such a concern, it is suggested that alternative arrangements are made.

Working in Varied Environments

Risk assessments must also be considered when arranging to meet at alternative venues. Other venues and considerations may include:

■ Community mental health resource centres or the team office base: consideration must be given to using personal attack alarms and ensuring other staff are aware of any response required if alarm is sounded

■ Alternative health and social care buildings such as GP surgeries: consideration must be given to any safety procedures including fire alarms, personal attack systems and how to notify resident staff when entering and leaving the building

■ Community leisure facilities such as libraries or sports centres: consideration must be given particularly to confidentiality.

Positive Risk Management

Positive risk management can be an important part of a care plan. To avoid taking risks is to limit opportunities to learn and develop, as everybody takes risks within their lives (Ryan and Morgan 2004, p. 230). However, pressures on mental health services to minimize risk and negative publicity have an impact on willingness to take risks. This in turn can jeopardize recovery, as opportunities are missed. A collaborative and positive approach to managing risk in occupational therapy should empower individuals, promoting a sense of responsibility, while considering the impact of identified mental health problems. Taking reasonable risk is about empowering people to make their own decisions and choices with appropriate support (Department of Health 2007). For example, graded activity could be used to minimize risk, informed by the stress vulnerability model.

The challenges to positive risk management are not just about avoiding adverse events. There are other pressures to minimize or avoid risk, generated by an emphasis on treating symptoms, judging effectiveness of services by avoiding admission and staff assuming a role as the expert, overriding service users. Services as a whole must seek a balance: between measuring risks and being the experts, favouring practices that are evidence-based; and empowering the person as the expert of their own experiences and makers of their own choices (Bonney and Stickley 2008). There is limited evidence about positive risk management. It can pose ethical dilemmas within practice, as services have a responsibility to protect the public yet also to protect the service user. Professionals can find themselves acting in the interests of the organization over the individual (Stickley and Felton 2006).

Personalization

The personalization agenda values people being in control of the support they receive from social services, to live their lives with individualized support as and when it is needed (Department of Health 2007, 2010). Similar in approach to the Care Programme Approach and positive risk management, the person is central to the process of identifying their needs. The structure of statutory services and funding arrangements can be unhelpful barriers, limiting choice about resources for care and support (Carr 2010). One of the barriers in the UK is the division between health and social care services. By focusing on individualized support and packages of care, empowerment and positive risk management are promoted. People are supported to use their strengths and make informed choices to live independent and fulfilling lives.

The personalization approach calls for a major change in how social services manage care (Raven 2010), encouraging creative and individualized thinking. By enabling people to identify what is required rather than use what is available in terms of social support, planning care is more about directing the financial resources available to individuals. Through the personalization agenda in the UK, eligible people are able to make use of self-directed support, personal budgets and direct payments.

Key Terms in the Personalization Agenda

Self-directed support is the mechanism through which individuals are able to access personal budgets. A self-directed assessment will give consideration to an individual’s circumstances, taking into account their whole situation including the needs of others providing support such as friends and families. Following assessment, an indicative budget is agreed, defining the amount of social care funding available to meet needs. A support plan can then be set-up based on the indicative budget and will be considered for approval by the local social care fundholders. Following approval, a personal budget is the amount of money that is allocated to and used by an individual to meet their support plan outcomes. A direct payment is one method of receiving a personal budget. The person receives the amount of money assessed as required into a personal bank account. They pay for the support that they require through a range of services, for example, private-sector care organizations, community groups, friends or family, in preference to statutory care provided by social services. Each individual should have support in devising their own support plan often through a member of staff within statutory services, for example, a care coordinator.

Not all individuals wish to manage their personal budget independently. In these cases, a notional budget may be arranged, whereby the individual is still aware of the amount of money available to meet their needs. The person agrees the support plan with, for example, the care coordinator. The care is arranged by the care coordinator to be provided by one of the existing social care service providers, who will then receive payment directly from the council. Alternatively, a third-party organization can be requested to manage the budget and employ the care service that is required on behalf of the individual. All arrangements are regularly reviewed to ensure that social care outcomes are being met through the services employed to meet people’s needs.

The ideas behind personalization echo the strengths model (Rapp 1998; Ryan and Morgan 2004) and the recovery approach (Anthony 1993), aimed at support and empowerment. The values of personalization have emerged from the independent living movement, which has promoted disabled people’s rights. Social workers have engaged with these values to argue for personalization within social care. Nosowska (2010) suggests that occupational therapists also should draw on their values and use their core skills to promote personalization.

MEDICATION

Medication has a large part to play in the management of mental health problems. It could be argued that it does not fit within the remit of occupational therapists, who are primarily concerned with occupational performance issues. However, if occupational therapists are to provide comprehensive interventions, then medication has to be a consideration because of the large part it plays in people’s lives. Two aspects of medication are considered within this section. The first is medication management as an activity. The second regards the effects of medication and implications for occupational performance.

Medications can be categorized into four major groups:

■ Antipsychotics: used for the treatment of psychosis, e.g. to lessen hallucinations or delusions and reduce agitation

■ Antidepressants: primarily used for the treatment of depression, although may also be licensed for some anxiety disorders

■ Mood stabilizers: used primarily in bipolar disorder to control episodes of mania

■ Minor tranquillizers: includes sleeping tablets and benzodiazepines. These are used for short-term sleeping problems and as sedatives for severe anxiety; also for short-term use only, due to addictive properties.

Medication Management

Medication is an important factor in a person’s wellbeing, where severe and enduring mental health problems exist. Often, people will be expected to take medications for indefinite periods of time, complying with instructions and adhering to the recommended regimen for taking medication, known as adherence. Medication management requires that the team is able to communicate effectively with a person to gain a clear agreement to promote good adherence (Mitchell and Selmes 2007). There is a significant rate of non-adherence with medication for many mental health problems. The reasons for this can be varied and may be defined as follows:

■ Cognitive difficulties: forgetfulness, confusion, memory, disorientation

■ Belief: faith, insight, hope

■ Knowledge: understanding of effects and side-effects, experience of undesirable side-effects, such as tiredness or increased appetite

■ Barriers to accessing services: chaotic lifestyles, difficulties with community travel, financial costs for attending appointments/paying for prescriptions.

Medication management must, therefore, be considered as much an occupation as brushing teeth. Occupational therapists provide advice and education that is within their professional scope of practice (College of Occupational Therapists 2013). When there are problems, as with any other occupation, it is important that the therapist aims to identify the reasons for non-adherence with medication. If there are poor routines or forgetfulness then specific prompts and reminders could be suggested, such as setting mobile phone alerts or placing a note on the fridge door. Some medications (e.g. clozapine and lithium) require regular attendance for blood tests and health checks. If a person does not keep an appointment, it is possible that some medications cannot be provided until the necessary health checks have been carried out. The occupational therapist could address issues, such as accessing public transport to attend for regular health checks.

Medication and Occupational Performance

While medications are used effectively by many people to reduce psychotic symptoms or improve mood, some may experience side-effects. These can include overtiredness, difficulty getting up or increased appetite. It is important that occupational therapists are aware of medications and their possible effects on people. This information can be used in the assessment of an individual’s occupational performance. However, the occupational therapist should always be careful to liaise with medical and nursing colleagues, to ensure it is appropriate to use interventions such as altering routines, adding exercise into daily activities and menu planning to ensure a regular healthy diet.

There may be some community settings where it is essential to have a greater understanding of medication, for example, a crisis resolution team. Medication may be crucial at particular times, to achieve the best outcome. The occupational therapist should know when to engage other team members. This decision should be informed with knowledge of commonly used medications, including:

■ Names of commonly used drugs

■ Common side-effects of each drug

■ Major contraindications

■ Form of drug – oral tablet or injection

■ Length of time for medication to take effect and expected outcome

■ Details of any blood monitoring and other health checks required and frequency

■ Action required if medications are not taken.

SERVICE SETTINGS

Community mental health services address diverse needs. In the UK, occupational therapists work in services such as crisis resolution and home treatment, early intervention in psychosis, community mental health teams, day services, assertive outreach services, personality disorder services, veterans’ services and liaison psychiatry services. Each of these services is briefly outlined below. Occupational therapists are also increasingly being employed by non-statutory organizations, including charitable organizations, not-for-profit companies and for-profit businesses. These are emerging and developing areas that present challenges and opportunities for occupational therapists, requiring the development of entrepreneurial skills (see Chs 8, 12 and 29). Regardless of the service provider or setting, the political importance of promoting mental health in the community supports the role of occupational therapy (Department of Health 2011).

Crisis Resolution and Home Treatment Teams

In the UK, NHS crisis resolution teams are required to provide a 24-hour and 7-days-a-week service for anybody experiencing an acute mental health crisis. They were established to reduce demand for inpatient care (see Ch. 22) (Department of Health 2000). Policy guidance defined the structure of teams and best practice (Department of Health 2001b). These specialist multidisciplinary teams offer a service to:

■ adults with a severe and enduring mental health diagnosis

■ adults with a personality disorder

■ adults with a co-existing mental health diagnosis and learning disability

■ the above, who are experiencing an acute crisis and, without the existence of a crisis resolution service, may require hospital admission.

The teams aim to:

■ provide comprehensive assessment of mental state and associated risk

■ act as gatekeepers for hospital admissions

■ provide a service to promote and facilitate early discharge from hospital

■ provide a care plan for intensive home treatment where this is a suitable option

■ continue with intensive home treatment until the individual is stabilized and referral to or transfer back to an alternative team can be made.

The teams are set up to provide high ratios of staff to service users to allow for up to 2–3 visits per day. The range of interventions carried out by the teams is varied and includes brief solution-focused interventions, practical problem-solving, medication management and support with daily activities.

Interventions within crisis resolution and home treatment services are brief, as once the crisis is resolved, it is likely that a discharge or transfer process will begin. Based on short-term goal-setting, interventions can include practical problem-solving, identifying and building on occupational strengths. People may be enabled to engage in self-care and leisure activities. It is important for occupational therapists within these teams to use a recovery approach, not allowing problems to become the prominent factor. Engaging in meaningful occupation can enable the person to rediscover their own strengths and coping strategies (NIMHE 2004).

Early Intervention in Psychosis

The rationale of early intervention is that intensive support at an early stage for people experiencing psychosis will reduce future need. Norman and Malla (2001) explored the duration of untreated psychosis and found that the earlier that treatment can be started, the greater chance that symptoms can be reduced. Specialized early-intervention teams have been developed internationally and evidence is still emerging of the effectiveness of the approach. Interventions focused on employment and family therapy have been found to be beneficial (Marshall and Rathbone 2011).

Early intervention services have two main objectives. The first is one of early detection, identifying and working with people with prodromal symptoms, which indicate there is a risk of developing psychosis. The second objective is to provide effective interventions for those who are newly experiencing psychotic phenomena, maintaining existing support mechanisms and social roles. This might involve promoting independence and recovery, emphasizing education and work-related outcomes. Many of the approaches and interventions are occupation-focused and supportive to the maintenance and development of life roles, requiring occupational therapy involvement.

Community Mental Health Teams

Where there is identified need following on from involvement with early intervention services, it is likely a person will be transferred to a community mental health team. These teams address complex needs, coordinating care from a multidisciplinary team. Within the UK, these teams may often be providing integrated NHS and social care services. They can include community psychiatric nurses, psychiatrists, social workers, occupational therapists, psychologists, pharmacists, arts therapists, cognitive behavioural therapists and support staff. They may also access additional resources, such as dietetics or physiotherapy as necessary. Some teams have been divided to provide specialist mental healthcare, according to diagnosis or need. For example, affective disorder teams alongside psychosis teams, or recovery and rehabilitation teams.

Based on collaborative working, the focus is on recovery and hope, while promoting good quality of life. Teams aim for the person to manage their life better. This can be achieved by enabling the person to identify a sense of purpose and meaning to their occupations, and form stronger relationships. Using a strengths-based approach (see above), a person is enabled to improve their chances of finding work, gaining education and maintaining suitable accommodation (Department of Health 2011). In this setting, occupational therapists aim to enable and empower individuals to become the makers and directors of their own existence (College of Occupational Therapists 2006).

Day Services

Mental health day services have traditionally fulfilled four main functions:

1. Short-term professional care

2. A place of safety or refuge during the day

3. A structured programme of daily or weekly groups for various purposes

4. A social context for peer support.

In the UK in the 1940s, it was recognized that people could receive mental health services without the inconvenience of hospital admission. Since then, day services have evolved and been subject to repeated scrutiny (Bryant 2011). The socially exclusive nature of some services has been observed, based on people attending for prolonged periods of time, segregated from their own families and communities, and emphasis on social activities, apparently to fill time. Based on this observation, modernization of day services has taken place (National Social Inclusion Programme 2008). The first function above is now often fulfilled by community mental health, crisis resolution and home treatment teams. Places of safety are less easily identified but can include non-statutory provision, such as drop-in sessions at resource centres. For the third and fourth functions, people are encouraged to join community activities open to all and peer support has developed in different ways in different areas (Walker and Bryant 2013).

Assertive Outreach

Assertive outreach teams aim to engage people who struggle to access services, often because they have limited insight into the effects of their mental health problems. Alternatively, they may have had compulsory inpatient treatment against their will and struggle to trust mental health professionals (see Ch. 22). Assertive outreach teams also work with people who are unable to easily access services due to chaotic lifestyles. Most people have severe and enduring mental health problems, usually a psychotic disorder. They would be vulnerable or would present with high levels of risk if not engaged and appropriate interventions provided with an assertive approach.

Assertive outreach teams were first developed in America in the 1980s to reduce hospital readmission rates, following the closure of many of the old institutions (Stein and Santos 1998). This followed in the UK in the 1990s.

Key features of assertive outreach teams are:

■ Staff to service user ratios of 1:12

■ Multidisciplinary teams (sometimes small discrete teams within a wider community team)

■ Team working approach (a caseload is shared among the team, although a care coordinator will be allocated to each service user)

■ Emphasis is on engagement of service user through an individualized, recovery-focused approach that draws on individual strengths

■ Intense support available including daily visits

■ Time-unlimited services

■ Interventions provided within the community and focused on non-mental-health resources

■ Daily team meetings.

The role of occupational therapists in assertive outreach teams varies. Some will be employed into specific occupational therapy posts and some will be employed into generic posts as assertive outreach workers, with the same job description as other nursing or social work colleagues. This variance has led to professional debate regarding the generic or specialist roles that occupational therapists find themselves in (Pettican and Bryant 2007).

However, assertive outreach requires a flexible and creative approach to engaging and establishing therapeutic relations. Occupational therapists within assertive outreach teams can focus on occupation for effective work with service users, identifying what is important to a person and where their strengths lie. Focusing on everyday life can provide a welcome break from a focus on symptoms and medication. This everyday life focus can include: self-care and domestic tasks; social and recreational opportunities; and work and education. Practical problem-solving can build hope for the future, which is essential in a person’s recovery (Slade 2009).

Housing

Housing problems and homelessness can be associated with severe and enduring mental health problems for many reasons, but often because of fluctuating support needs over a long period of time. The issue of housing is historically linked to deinstitutionalization with the closure of large hospitals and the shift of resources from inpatient to community settings. Nelson et al. (2012) highlight the issue that, for a proportion of people, deinstitutionalization has led to less secure accommodation with people more likely to be homeless or involved in the criminal justice system. The prevalence of psychosis is 4–15 times as high among the homeless population, increasing to being 50–100 times more likely in the street homeless population (Rees 2009). As the stability of housing increases, then rates of serious mental health problems decrease.

Supported housing offers different levels of support according to need; with an expectation that people will progress through services from levels of high support to levels of low support (O’Malley and Croucher 2003). For people with severe and enduring mental health problems, this assumption may not reflect their ongoing needs and has led to instability in housing. Rees (2009) suggests that close working between housing, substance misuse and mental health services, with assertive approaches, achieves more positive outcomes.

The role of the occupational therapist involves working with the individual to identify the most suitable accommodation to meet their needs. There will also be work to develop skills to support their security of tenancy and progression to less supported environments (see also Chs 19 and 21).

Personality Disorder Services

Borderline personality disorder is characterized by instability in interpersonal relationships and impairment of social, psychological and occupational functioning (NICE 2009). This combination of difficulties raises challenges for community mental health services and so specialist services have been established in some areas. The prevalence of personality disorder has been estimated at 4.4% (Coid et al. 2006), with a predominance in urban areas and among men.

Key interventions are similar to other approaches to working with people with enduring mental health problems. Identifying long-term goals, including those relating to employment and occupation, should be carried out in collaboration with the individual. These goals should then be linked to realistic and achievable short-term objectives. Psychological approaches that support people to live with a diagnosis of borderline personality include dialectical behaviour therapy (DBT) and systems training for emotional predictability and problem-solving (STEPPS) (Federici and McMain 2009). Psychological approaches may inform occupational therapy for those in generic roles.

Military Personnel and Veteran Mental Health Services

Reactions to, and experiences of, traumatic events can lead to a range of mental health problems. Armed conflict is a reality across countries and regions around the world, adversely impacting on everyone in the area. The welfare and mental wellbeing of military personnel and veterans has renewed prominence due to the long involvement of the military in Iraq and Afghanistan. Occupational therapists have promoted their role in the treatment and management of Post Traumatic Stress Disorder (PTSD) (Baum and Michael 2008). They argue that, in addition to medication and talking, therapies that focus on functioning through social and other therapeutic activities are critical to recovery. In the UK, the NHS has dedicated web pages providing information on this issue (NHS Choices 2013).

Liaison Psychiatry

Liaison psychiatry teams provide the interface between mental health and physical health. The teams provide specialist mental health assessments to people in general hospitals. These may be people who are experiencing difficulty in adjusting to physical health problems or who have psychological comorbidities. They will also attend to people who have self-harmed and will carry out a comprehensive mental health and risk assessment. A person may then be transferred on to one of the other community mental health services.

Where there are felt to be occupational needs, occupational therapists are often accessed through other teams, either within the general hospital or via the other community mental health teams according to need. There are a growing number of occupational therapists within older people’s liaison psychiatry teams.

CONCLUSION

The different community settings outlined offer many opportunities and challenges for working with people with severe and enduring mental health problems. Using supporting models and approaches can enhance practice and the experience of the person receiving services. Awareness of historical and current issues, as well as being alert to emergent themes, can aid appropriately responsive collaborative care.

Occupational therapists at times struggle to maintain professional identity: multidisciplinary teams may exert pressure for the therapist to work generically, while professional groups have an expectation that a specialist role is retained (Lloyd et al. 2004). The reality is that occupational therapists undertake a dual role and are competent mental health practitioners. Care coordination and recovery-oriented practice recognize and support the skilled use of occupation as a therapeutic medium. There is also the need to work flexibly to best meet people’s needs. It is suggested that occupational therapists prefer more of both generic and specialist roles (Lloyd et al. 2004). Responding to current demands and expectations requires a clear focus on how to make the most effective and efficient contribution, within diverse community mental health teams and services.