Bringing the help to home

been forced out of her accommodation, leading to delayed discharge from hospital. Such a course of events would inevitably have attracted the label of 'relapse of schizophrenia'.

"I can't go on"

Later we are asked urgently to assess for admission a 30 year old man who is anxious and depressed. Aaron has had no previous involvement with psychiatric services. His wife had left him two days earlier and he had been drinking heavily since, in which heavily inebriated state his sister had found him. His mood depressed even further by the alcohol, he had announced dramatically that he could not go on, frightening her enough to summon his GP. His GP, in turn not confident that Aaron wouldn't harm himself, had called on us.

We decide that home treatment is not appropriate. We are reluctant to view his crisis in terms of mental illness but rather as an understandable reaction to distress and don't consider Aaron to be suicidal. (Sometimes, in their distress, people drinking heavily are willing some desperate course of action, such as hospitalisation, to occur. It can on occasions be very difficult to judge if they are in danger of harming themselves or others but previous history is an important guide in such cases.)The team makes arrangements for Aaron to have relationship counselling and help with his alcohol problems.

Only half of urgent cases assessed are offered home treatment. We have to focus on individuals who are otherwise likely to be admitted to hospital because of the severity and nature of their problems. Resource allocation to develop home treatment has to be at the price of some other feature of the service, and this is primarily reduced inpatient beds. Even if we could help a lot of less seriously distressed people, the home treatment team is not sustainable unless it reduces hospital admissions for severe conditions.

A crisis for Emma

The next day begins with a crisis for Emma, a 23 year old woman with depression and a history of repeated self harm who has been on home treatment for two weeks. She lives with her mother and has again been having intense thoughts about cutting her arms. She had recently started cognitive therapy for an incident of rape when she was 15, which resulted from a relationship with a much older boyfriend. Her mother had found it very difficult ever to talk about the trauma of the rape, having intensely disapproved of the relationship in the first place. The friction between the two had increased since Emma began the therapy, with her mother now further withdrawn and openly disapproving when Emma harmed or threatened to harm herself. She wanted Emma admitted to hospital. Emma felt rejected and her self esteem was low.

When we visit, Emma is ambivalent about admission. During a previous admission she had cut her wrists and ended up a compulsory patient on special observations for a week. We are concerned, however, with the difficult situation between herself and her mother at home, especially as she says she cannot guarantee that she will not resort to serious self harm. Although we feel we cannot leave her there, nor are we happy about admitting her, especially in the light of her last experience. The team arranges instead for her to go to a respite facility run by service users where a place will be available the following day. Home treatment support will be shared with the staff at the respite facility, all of whom are in recovery from mental health problems. A joint care plan is discussed and agreed. An essential requirement is that Emma has to guarantee that she will not hurt herself and, in this setting, Emma is prepared to do this.

The arrangement allows for Emma to receive additional understanding and help from the 'expertise of experience' alongside professional expertise. She receives counselling from the team which concentrates on helping her develop confidence in her ability to have other successful relationships and understand the rape in terms of her understandable immaturity and inexperience, and acknowledging how traumatic the experience had been for her.

Admission to hospital is commonly the only available resort when 'respite' is required. The notion and need for rest and getting away from stressful situations is an important one, but the benefits of hospital admission in providing this are often outweighed by the disadvantages. While patients greatly value the nursing care in acute admission wards, there can be an undue emphasis on medicalising problems into symptoms and on behavioural conformity, with restricted freedom in tense environments. Many home treatment teams have found that family sponsor homes and non—hospital respite facilities are preferable in meeting the need for respite. In crisis, control of oneself can be easily jeopardised and lost. Maintaining a degree of control and choice is facilitated by home treatment, as it is so personally tailored to individuals and their problems.

John makes progress

John is beginning to settle and talk more appropriately about the difficulties in his job. The restaurant he managed had been losing money and he had been working very long hours trying to remedy the situation entirely by himself. He had been threatened with dismissal by the owner who had not allowed him to display initiative and his own style. Having failed in a previous venture, he was very frightened of losing his career and had begun, after many years, to pray, find solace in the Bible and attend church again. He is now oversedated and his speech is slurred. We begin to taper his medication downwards.

Daily administration, supervision of medication and monitoring clinical response is a routine but skilled task undertaken by home treatment teams, just as inpatient staff carry it out in hospitals.

John receives acute home treatment for four weeks and then sees me as an outpatient for six months for follow up. He becomes manager of a smaller restaurant which he finds less stressful, and his case is transferred to psychiatric team and GP in his home area.

Fred will not open the door

In the afternoon we decide to arrange admission for Frederic, a 50 year Polish immigrant with paranoia resulting from a serious head injury 15 years ago. He lives alone and is claiming that the NHS is involved in a conspiracy against him. Seeing the letters N, H, and S on the registration plates of passing cars is, for him, proof of the conspiracy. He had initially engaged quite well with the team members, but had begun to express doubts about their true intentions during the first week. His self care and nutrition is poor and he had been losing weight. He has been getting slower and slower at opening his door when the team calls (sometimes taking 15 minutes to appear) and is now frankly refusing what he perceives as the interference of the team. He is particularly annoyed about the restoration of medication which he said he had been taking for too many years. Conversations both the night before and this morning have had to be conducted through the letterbox. The process of admission is an unhappy one, involving the police and the use of the Mental Health Act.

All mental health professionals recognise that there is a point of no return when the level of concern about someone reaches the stage of considering compulsory admission, despite all the problems and discomfort for each party that this creates. Home treatment teams are no different in this respect from conventional services, although our remit is, whenever possible, to offer a 'third way' when someone needs treatment but doesn't want hospital admission. In Frederic's case, we recognise that we are getting nowhere, and both his mental and physical health are deteriorating. Prevention of admission 'at all costs' is a dangerous ideological position as far as sound clinical care is involved and one not held by home treatment teams.

Meanings of mental illness

Home treatment, in offering an alternative response and treatment setting, emphasises certain principles and values. Staff report how the personal relationship and practical collaborative journey with people who have significant mental health problems become a highly important and rewarding element. The dialogue that develops is more flexible in respect of theoretical models and is a response to an individual's particular experience and problems, allowing especial focus on the meanings mental illness may have in the context of that person's life. We talk, for example, of voices rather than hallucinations or religious beliefs rather than delusions. With this less medicalised approach, it is easier to remove institutional and professional therapeutic constraints, and surely this is a good thing. While it is the goal in most mental health strategies to respect autonomy and enable personal empowerment, the setting, flexibility and personal tailoring which home treatment incorporates enlarge this opportunity, and allow the challenge of doing so at a highly critical juncture in a person's life.

How successful is home treatment?

OVER 25 years of research has shown home treatment to be equally as or more effective than hospital admission, and to be very significantly preferred by service users and carers. Studies of home treatment have looked mainly at patients with severe mental illness, with psychosis accounting for three quarters of cases. They show that:

- home treatment is safe, effective and feasible for up to 80 per cent of patients who might otherwise be admitted to hospital.[1,2,3,4,5,6,7,8] Five reviews have endorsed the findings. [9,10,11,12,13]

- home treatment can reduce admissions to hospital by on average 66 per cent [1—7] (the least being by 55 per cent, when based on adequately randomised controlled studies only) [10]

- home treatment can reduce length of hospital stay by up to 80 per cent.[14]

- there are lower levels of burnout and significantly higher job satisfaction in home treatment teams.[8]

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References >>

This article first appeared in Volume 7, No, 3 (2000) of the Human Givens journal.

PROFESSOR MARCELLINO SMYTH is a general adult psychiatrist at North Birmingham Mental Health Trust and an honorary professor in social and community psychiatry at the University of Central England (Centre for Mental Health Policy). His main academic interest is in evaluating the extent to which new service models can impact on individuals receiving psychiatric care and their relationship with psychiatric services.