Journal of Mental Health, February 2010; 19(1): 75–87
REVIEW
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
Service users’ experiences with help and support from crisis resolution teams. A literature review
MONIKA GULLSLETT WINNESS*, MARIT BORG*, & HESOOK SUZIE KIM Department of Health Sciences, Buskerud University College, Kongsberg, Norway
Abstract Background: Services for crisis resolution provided by home treatment teams are recent developments in the mental health care scene. There is a lack of systematized reviews in the service users’ responses to these services. Aim: To systematize the existing knowledge regarding the service users’ experiences with crisis resolution and home treatment (CR/HT) teams in order to explore ways to develop this form of service further. Method: A systematic review of the periodical literature and research reports on CR/HT was carried out for the period from January 1995 to January 2009. Results: A total of 13 papers, one RCT review and two reports were identified, including both qualitative and quantitative studies. Although these studies provided few in-depth details, three major themes as the characteristics of CR/HT teams are extracted as: (a) access and availability, (b) being understood as ‘‘normal’’ human beings, and (c) dealing with crises in an everyday life context. Conclusions: The findings suggest that the key positive characteristics of help in crisis situations are intrinsically tied to the values and principles undergirding CR/HT services. The commitment to community-based services, the philosophy of partnership, and user-empowerment seem to the base from which these three themes of positive experiences emerged.
Keywords: User experiences, mental health crisis, home treatment, crisis resolution, recovery
Introduction Various forms of ambulatory mental health crisis teams have been developed and integrated as parts of community services in different countries throughout the past five decades (Brimblecome, 2001; Joy, Adams, & Rice, 2006). While this shift to community mental health care during the earlier decades was mostly designed within the movement for deinstitutionalization, the more recent developments have also incorporated user-oriented rationales. User-involvement in mental health services has been of critical importance in the advancement of community care. User-involvement is thought to be more possible and more meaningful in home care situations than in hospitals, as service users would be more Correspondence: Monika Gullslett Winness, MSc and Research Fellow, Buskerud University College, Department of Health Sciences, Box 235, 3601 Kongsberg, Norway. E-mail:
[email protected] *Both these authors contributed equally to this work and should both be regarded as ‘‘first author’’. ISSN 0963-8237 print/ISSN 1360-0567 online Ó Informa UK Ltd. DOI: 10.3109/09638230903469178
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
76
M. G. Winness et al.
able to articulate their problems contextualized to their everyday life situations and receive help remaining in their homes. However, user involvement is not an easy and conflict-free change of practice, and its incorporation into service designs has been a slow development due to the persistence of medicalization and professional control. As one form of community mental health care, crisis resolution and home treatment (CR/ HT) teams have been instituted with an aim to maximize opportunities for acute care whilst allowing service users to remain at home. The literature on CR/HT has mostly focused on issues pertaining to service development, clinical methods, and professional practices as both the professionals and administrators were keen on gaining knowledge critical for its implementation (see for example, Joy et al., 2006). While it is interesting and important to have a comprehensive knowledge about the CR/HT service from the organizational and professional perspectives, there is also a need to assess what the state of knowledge is regarding service users’ experiences and preferences if we are to improve the practice. The focus of this paper is to identify and discuss service users’ experiences of CR/HT teams, especially in terms of how users find this form of service helpful through a careful review of the existing literature. Background Adult mental health service provision in the western part of world is in a period of rapid change seeking to expand non-institutional care for people with mental health problems. One central area of attention is the acute mental health services, regarding which a great deal of criticism has been raised by service users and their families as well as by professionals. The criticism addresses administrative aspects such as inaccessibility and insufficiency as well as quality including an overt medical orientation, excessive use of coercive treatments, and the lack of users’ involvement in treatment planning (Beresford, 2005; Borg, 2007; Kogstad, 2009). Mobile crisis teams configured in a variety of ways in terms of service profile, professional roles, and rationale for targeting the service have developed in many countries over the recent decades. The main objectives of such teams have been to target reducing hospital admissions, shortening the length of stay, and providing more available and safe services (Brimblecome, 2001; Johnson, 2007; Morgan & Hunte, 2008; Thornicroft & Tansella, 2004). In such teams the emphases have been placed on a multidisciplinary service approach, a low patient-staff ratio, an ability for rapid assessment, a short term care (4–6 weeks), and attention both to clinical and social needs (Heath, 2005). The standards by which such teams provide services vary a great deal especially in terms of 24/7 availability and the gate-keeping role. Additionally, there is no standard position regarding how service users’ expertise and preferences would be integrated into the development of such teams even when their orientation is in people’s needs. This is rather surprising in the current culture where empowerment and consumerism have become central to various aspects of social life, and user involvement has been encouraged in all sorts of social activities. It is also surprising that newer and revisional understandings that have come forth in the recent years regarding subjective experiences of recovery have had so little impact on developing new community services such as CR/HT (Boevink, 2005; Borg & Davidson, 2008; Deegan, 1997). As there are many different terms used to designate acute mental health care within the community mental health, we use the term ‘‘crisis resolution and home treatment (CR/HT) teams,’’ as this is the term used in public reports both in UK (Morgan & Hunte, 2008) and Norway (Sha, 2006).The definition of CR/HT used in this report is: CR/HT refers to a service design for acute mental health care provided by a team of multidisciplinary
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
User’s experiences with help and support from CR/HT
77
professionals in the context of users’ ordinary homes. In our review of the literature we have applied this term as the guiding label, as some studies called such services with different terms. We have adopted the term service user, since this term has replaced the terms, ‘‘patient’’ and ‘‘client,’’ in the mental health literature as well as in the health service sector in recent years. Our approach to this review was to reveal what the service users found their experiences with CR/HT to be positive. Because CR/HT has been developed as a form of mental health care guided by a set of principles with a specific aim to provide better care to service users than through acute hospitalization, we focused our review on revealing in what ways this aim has been met from the service user perspectives. The research question, therefore, was: What did the service users of CR/HT find that was positive and satisfying as revealed in the literature?
Method Selection of studies for review The method used for this study was a comprehensive review of the literature. We identified studies for possible inclusion by combining searches of electronic databases, hand searches of reference lists of papers, and purposive hand search of grey literature. We selected the following keywords and MESH terms/Subject Headings in two sets specified as ‘‘crisis resolution’’ and ‘‘service user experiences’’ which were then used for the search in all possible combinations across two sets: the terms for ‘‘crisis resolution’’ were crisis resolution, crisis assessment, crisis intervention, intensive home treatment, and home treatment; and the terms for ‘‘service user experiences’’ were user experiences, user perspective, client attitudes, subjective experiences, patient satisfaction, consumer satisfaction, and client satisfaction. The selected databases from EBSCO were CINAHL and ISI, and the OVID bases included Psych info, Medline, Embase, and British Journal of Nursing. In addition, we used Google Scholar and SweMedþ. We also made a search in the Cochrane library database and found one review of relevance for this study. In addition to the matches on search terms, we included related studies that were relevant from the articles’ reference lists and consulted international researchers. From the initial search process 624 papers and reports were identified. From this total set, papers were selected by the following inclusion criteria: (1) (2) (3)
Papers published during the period 1995–2009, Papers having an empirical research base, Papers addressing service user experiences with acute mobile/ambulatory mental health care.
We examined the abstracts of all papers and reports identified in the initial search (if an abstract was not available, we perused the paper for a brief reading) in order to determine whether or not the papers addressed the content area of our interest. Papers included are those describing the service user experiences of help and support from acute mobile teams in mental health crisis situations as well as papers about service user satisfaction with crisis help at home as opposed to hospital admission. It is difficult to characterize one specific standard of services by CR/HT teams, or the fidelity criteria regarding opening hours, referral routines, types of user groups, service providers, interventions, and ideology. Therefore, we included the literature on home-based crisis services of which the goal was to avoid inpatient admission or facilitate earlier discharge. Both quantitative and qualitative studies were
78
M. G. Winness et al.
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
included. Studies dealing with crisis caused by disasters such as accidents and catastrophes, somatic disorders, brain damage, and substance abuse, studies on carers’ or providers’ views, and studies on child and adolescence were excluded. Most of the 624 papers did not deal with user experiences; instead they were studies about administrative and organizational aspects of CR/HT teams or regarding disasters of more general character. Because the characteristics of more recent development of CR/HT are different from those developed in earlier decades, we included publications from 1995. Thirteen papers, two research reports, and one Cochrane review were identified and were reviewed in detail for this paper (Figure 1). Review analysis The two first authors read all 16 reports, and analyzed the contents for findings related to how users experienced and coped with the crisis situation and made use of the CR/HT
Figure 1. List of the studies included in the review.
User’s experiences with help and support from CR/HT
79
services, with particular focus on what was found helpful. The analysis was carried out independently by each author as the first step, followed by comparing and modifying findings, as well as searching for higher-order connections and issues.
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
Methodological limitations The limited number of studies included in the review can challenge both the internal and external validity of this review. However, it was not surprising to find only a small number of studies addressing user experiences with the services and of crisis, as CR/HT is a recent development and investigations into user experiences have only just begun in recent years. The research designs adopted in the reviewed papers were varied in relation to methods and selection of participants. The reviewed studies cover a range of heterogeneous services in terms of the forms of services and organization. Findings Although the services referred to in the studies were different in their practice philosophy and organization, certain issues shared common threads. In all the papers the major objective of the CR/HT was to provide a service of equal or better quality than inpatient care, and to improve client satisfaction by preventing hospitalization or creating more humane and better planned admissions, and to reduce the length of stay in hospitals when inpatient admissions result with CR/HT service (Brimblecome, 2001; Joy et al., 2006; Kalucy et al., 2004; Robin et al., 2008; Scott, 2000; Whittle & Mitchell, 1997). In general the positive experiences of help revealed in these studies were related to crisis services that made it possible to stay at home and carry on with normal patterns of daily living. They appreciated flexible professionals who were open for negotiation and personal choices, and were interested in users’ own coping strategies and understanding of the situation. Including family members was also appreciated (Hopkins & Niemiec, 2007; Karlsson & Hultberg, 2007). Results from three of the included quantitative studies indicate that the patients’ satisfaction is significantly higher with CR/HT teams than with inpatient treatment (Johnson et al., 2005a; Johnson et al., 2005b; Scott, 2000). On the other hand, certain unhelpful issues were also disclosed in the studies, such as feelings of discontinuity in the service, a short follow-up care, staff shortage, a long wait for care, and a lack of information on medicine and illness (Ampelas et al., 2005; Clark et al., 2007; Hopkins & Niemiec, 2007). It is interesting that most of these negative experiences are closely related to organization of services rather than the processes of practice. Three themes emerged as critical components of CR/HT in these studies from the service user perspective: (a) access and availability of immediate and home-based services, (b) being understood as ‘‘normal’’ human beings, and (c) dealing with crises in an everyday life context. Access and availability Typical service qualities identified as positive were easy access and rapid response when help was needed. Examples mentioned by service users were opening hours with availability of 24/7, opportunities for telephone contacts when needed, and flexible referral routines. The availability for immediate help in the home context seemed to normalise crisis experiences and strengthen individuals’ as well the family and networks’ coping strategies
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
80
M. G. Winness et al.
(Goldsack et al., 2005; Hopkins et al., 2002). In some studies the service users’ reported that just knowing that a mobile crisis team was available made them feel safe (Coleman et al., 1998). The accessible and often comprehensive support provided by the crisis team helped people to stabilise and get back to everyday activities more quickly. This was particularly so in early phases of the crisis, and also seemed to prevent breakdown in the family system (Clark et al., 2007; Hopkins & Niemiec, 2007). Furthermore the accessibility in the form of an open communication among users, professionals, and family members was highly valued (Hopkins & Niemiec, 2007). The service users found a helpful, accessible support system in CR/HT teams in which the care was designed to improve coordination among various providers. Since persons in mental health crisis were often in need of available practical help in a variety of areas such as social benefits, work, child-care or accommodation, a well-coordinated service among CR/HT teams, hospital based services, and other social service sectors was viewed by the service users as integrated and efficient. A safe and well-organised discharge planning from the CR/HT was also described as important. Helpful ways in discharge planning identified were ensuring enough time in linking with other providers, emphasising safety, direct communication and providing useful information, and jointly developing detailed skills-oriented crisis plans (Goldsack et al., 2005; Hopkins & Niemiec, 2007; Karlsson & Hultberg, 2007). Being understood as a ‘‘normal’’ human being In several of the studies such aspects as respect, being listened to, being trusted or being counted on were emphasized. Being treated respectfully was important to service users (Karlsson & Hultberg, 2007). A positive help in these situations involved the professionals giving the user a feeling of being taken seriously, being treated as a resourceful person, being responsible for one’s own recovery process, and being allowed to bring change to one’s life when one is ready for it. This also meant being treated as ordinary, normal persons (Hopkins & Niemiec, 2007). Approaches incorporating these aspects seemed to strengthen the feeling of self-control and responsibility, followed by a sense of safety, neutralization of the crisis, and humanized experience of crisis (Goldsack et al., 2005; Kalucy et al., 2004). Open-minded reflections and negotiations among the service user, social network, and professionals provided the service users with a feeling of support to follow the recovery process on their own terms. For instance it seemed important to the service user to be visited by the professional when and where he/she preferred it and to remain in contact as long as necessary (Ampelas et al., 2005; Hopkins & Niemiec, 2007; Kalucy et al., 2004; Karlsson & Hultberg, 2007). Dealing with crises in an everyday life context The experience of safety in the crisis situation while staying at home was referred to as important. Being at home also seemed to give hope and faith in reducing the mental distress and also encouraged carrying on with some of the day-to-day activities within the ordinary social networks. The involvement of family and network was promoted when services were available for those involved (Morgan & Hunte, 2008; Robin et al., 2008). The support from CR/HT teams gave opportunities, both for users and carers, to deal with and overcome everyday life activities and incidents, such as getting the household organized, taking a shower, taking medication, using public transport, and shopping (Goldsack et al., 2005).
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
User’s experiences with help and support from CR/HT
81
Staying at home meant continuity in their social life, carrying on ordinary activities of everyday life (Kalucy et al., 2004). Service users also appreciated the providers’ presence and availability for ordinary talks if needed (Goldsack et al., 2005; Hopkins & Niemiec, 2007; Kalucy et al., 2004). Some studies emphasized the effects of the professionals’ cultural competence involving considering and meeting cultural minority groups’ needs such as religious practices, diets, faith healing, and language (Khan & Pillay, 2003; Ruggeri et al., 2006). One study referred to the importance of food to Asian service users since food was a central issue in their everyday life (Khan & Pillay, 2003). These themes point out that service users desired to be taken as ordinary people who can carry on with their lives in spite of their acute crisis and mental distress. Being able to receive services from an accessible system when in need of immediate help was important to them, as also was being respected for their own understanding of a crisis situation and having an interest shown in their preferred solutions. Discussion We present our discussions in this section framed within the fundamentals of CR/HT as articulated by Karlsson and colleagues (2008). Karlsson and colleagues advanced a framework for CR/HT in which they identified a component of CR/HT fundamentals as ‘‘the values, principles, and philosophies that undergird this form of service,’’ and identified (a) commitment to community-based care, (b) importance of co-ordinated services among different areas of services, (c) philosophy of partnership, (d) the primacy of user empowerment as the precondition for recovery, and (e) the necessity of coordinating resources for best care as the fundamentals (Karlsson et al., 2008, p. 213). Since these are principles with which CR/HT is generally created and implemented with the aim of improving services to the users, it is appropriate to frame our discussion of the positive aspects of users’ experiences with CR/HT. Three themes that were identified as the positive aspects of the users’ experiences in this review will be discussed posing them in relation to these fundamentals. Access and availability This theme is related to the positive aspects of how CR/HT teams are structured to provide access and availability of services to users. CR/HT teams, applying the fundamentals of community-based care, coordinated services, and resources coordination, are oriented to be more accessible and available to service users than hospital care. Articulation of this theme as one of the positive user experiences with CR/HT teams suggests that in general CR/HT teams work with a greater degree of flexibility in providing services than the degree with which the acute hospital services can. This theme suggests that services with flexibility and fewer obstacles to users produce positive experiences. It is often that service users become frustrated, and distressed because they are not able to make contact with service providers when they need them or they find various obstacles that prevent immediate access or immediate resolution. Although none of the reviewed studies framed their work on a model of health services utilization, it is possible to examine this theme within the Andersen model of health services utilization (Andersen, 1995). Why people use specific health services or use health services at all has been examined in the social sciences literature since the 1970s. The Andersen model (1995) includes users’ attitudes as one major component of service use, and the structure of services themselves as
82
M. G. Winness et al.
being enabling factors. It is possible to consider that the fundamentals for CR/HT are oriented to establishing CR/HT teams that enable service users to be attracted to them as well as providing positive attitudes to users regarding their services. Although we do not know how the crisis intervention teams, with which the users had experiences, had carried out their services, or in what organizational contexts they worked, the service users’ responses could have been influenced by the expectations and attitudes they had developed through previous experiences with psychiatric services.
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
Being understood as a ‘‘normal’’ human being This theme upholds two fundamentals: philosophy of partnership and user-empowerment. When service users perceive that they are viewed as persons with the capacities for autonomy and decisions, dignity and respect, and trustworthiness, they are able to participate in the care processes as equal partners, and would be empowered to reveal their own expertise. Being trusted means being treated as an autonomous person, believing one’s experiences to be true and worth attention. Experiencing trust and feeling as a fellow human being in the helping relationship represented a valued role and partnership for the service users. The philosophy of partnership is based on equalizing power differences and mobilizing strengths in participants in a non-competitive fashion. This would only be possible when participants are mutually respectful of their humanity. Attributing ‘‘normality’’ to service users by the professionals and perceiving such a view by service users is the first movement away from the power imbalance in professional-user relationships. This concept of normality is especially critical in mental health care in which traditionally people with mental health problems have been marginalized and powerless, and put into dependent positions. The concepts of partnership and user-empowerment have been introduced into the field of health care in general and in mental health care more particularly in this postmodern culture advocating for self-determination and power-balance during the past three decades. As Rappaport (1987) suggests in his proposal for a model of empowerment in health care, empowerment upholds the capacity, knowledge, and power people possess for their own affairs, and is actualized by allowing people to participate in decisions affecting their lives. Therefore, empowerment and participation are interlinked to process self-determination and personal responsibilities in health care. Fitzsimons and Fuller (2002) in their review paper noted that community-based empowerment approaches have gained their placements in mental health care, and Rijckmans and colleagues (2007) labelled a form of service, a demand-driven health care, in which service users are empowered to participate in decisionmaking processes, and found in their survey of ambulatory mental health clients that they valued being heard and being involved in the process of decision making as serious partners. Laugharne and Priebe (2006) also found in their review paper that mental health service users in general value having choice in their interactions with professionals, being given information about their problems, and having a voice in treatment decisions. Professionaluser relationships that foster partnerships and empower users are the routes to gaining common understanding of crises situations and finding ways to approach the situations. For such relationships to develop it is necessary for service users to feel normalized and to perceive respect as persons. Dealing with crisis in an everyday life context This theme is directly tied to the work of CR/HT as a community-based service. A person placed in a context instituted on the medical model becomes a patient, who is cared for in
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
User’s experiences with help and support from CR/HT
83
that model primarily structured by diagnosing and therapeutics, although Bridget and Polak (2003) suggest that a psychiatric admission is both medical and social. Although the validity and reliability of psychiatric diagnoses and the assessment procedures that lead up to them are criticized (Read, 2004; Wilson & Beresford, 2002), this is the foundation and core of acute hospital psychiatry. In the acute hospital the person is situated in an environment (i.e., the hospital) that is separated from the everyday life social context within which mental health problems were experienced. A fundamental criticism of the medical model is that pathological discourses rarely consider the person’s life circumstances or bring in considerations from the relational, social, and contextual perspectives (Borg et al., 2009; Bridgett & Polak, 2003). When a person with a mental health crisis is offered home treatments, it may be more likely that the person is met as a person rather than as a patient. Of course, this does not mean that professionals in community-based services will necessarily meet service users as persons rather than as patients and not be committed to the medical model. However, when health care is provided in a service user’s home, it is more likely that service providers will see who the service user is as a person, what the service user’s strengths and weaknesses are, and how that person functions in the social context of everyday life. As emphasized in recovery research, help and support is best given in the person’s natural environment in everyday life (Borg, 2007; Onken et al., 2007). This means that mental health crises may be defined in the medical model differently from the social or life-world model, thus circumscribing different approaches to care. While an understanding and definition of mental health crisis can be gleaned from the general conceptualization of crisis as in Caplan’s psychological model (1964), it can be understood differently as a socially constructed reality. From this perspective, crises are to be viewed as contextually embedded happenings that are intricately webbed with life situations (Szasz, 1974). Cullberg (1978, 1999) refers to four central psychosocial aspects of mental health crises – the provoking situation, the person’s biography and developmental history, the present life period, and the person’s social situation. From this perspective the change of arena from hospitals to home-based services enhances a shift of power for control from professionals to service users and a focus on the person and everyday life situation for understanding problems. An interesting aspect in the recent developments of CR/HT teams is that limited attention has actually been given to understanding what mental health crisis means both to professionals and service users (Karlsson et al., 2008). It would be critical to address the following questions for a greater degree of understanding about mental health crises in the context of CR/HT: What is the individual service user’s theory of crisis; what is the providers’ understanding and how do they explore ways of responding to them? Such questions could be posed for critical understanding from the Foucaultian perspective addressing his claim that all ideas and understandings are historically, culturally and socially specific, but that some concepts and ideas have become so widely accepted that they are taken as truth (Foucault, 1967, 1973). In addition to the shift discussed above of meanings and frameworks for definition and care for mental health crisis in community-based mental health services, the experiences in and over crises would be shifted also when the service location is changed from hospitals to homes. To carry on with normal life at home during crisis can strengthen the person’s capacity to be an active agent in his/her situation and also find ways to deal with and overcome crisis in the context of one’s everyday life situations (Goldsack et al., 2005; Hopkins & Niemiec, 2006; Karlsson & Hultberg, 2007). If the person is removed from the daily context where problems appear in crisis situations, this opportunity is taken away from the person and the crisis becomes purely a medical issue.
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
84
M. G. Winness et al.
A critical part of understanding the impact of CR/HT services is through the knowledge of service-user experiences. The impact of CR/HT on service-users is not limited to changes in accessibility to service, responsiveness of service-providers, and satisfaction in relation to participation and user focus, but extends to more fundamental changes such as reorientation from illness-focus to individual strengths and an emphasis on personhood rather than patienthood (Karlsson et al., 2008). Investigating subjective experiences of mental health problems and with mental health services can provide insights into both the positive and negative experiences (Borg, 2007). Such subjective experiences can also reveal the processes people use to make life easier during mental health crises as well as the meanings people have in relation to building on strengths, carrying burdens, and encountering troubles (Borg & Davidson, 2008). Our examination suggests direct and indirect associations between these positive themes that were extracted from the literature regarding service users’ experiences and the fundamentals that are the basis for the institution of CR/HT. The commitment for community-based mental health care as the starting point for CR/HT seems to be critical in affecting service users positively. It seems that community-based mental health care does not just change the locality of service settings from hospitals to homes, but along with this shift the dynamics of service provision may also change to embrace the philosophy of partnership and user-empowerment. Needless to say, a commitment to the philosophy of partnership and user-empowerment does not have to exist in community-based services only, but community-based care by its design is more amenable to embrace these fundamentals. Implications for practice Transforming the roles of professionals and service users towards partnership that is open for negotiation and characterized by equalized power bases involves major changes in philosophies, attitudes and daily practice, and requires participants, both professionals and service-users, to review and critique local truths and traditions for understanding and transformation (Karlsson et al., 2008). Since CR/HT teams are founded upon the values and principles that foster user participation and empowerment, it is critical for professionals involved in the provision of CR/HT to examine the processes that are being used to bring forth these values and principles into practice. It is furthermore imperative for practitioners as well as managers to listen carefully to service users’ definitions of the situations as well as to cultivate the service users’ expertise in managing mental health crises at home. One of the important practice processes that enhance this orientation is to invite life stories rather than illness stories from service users as the starting point, as life stories are more likely to reveal crucial information about living conditions, socio-economic experiences, patterns of usual social interactions, and personal preferences, all of which are central to the processes of recovery and cannot be seen as lying outside of the scope of crisis services (Borg & Davidson, 2008). Additionally, when a CR/HT team gets established as a part in the reorganization and decentralization of mental health services, there is a need for involved professionals to examine the meanings and impact of the shift in the practice philosophies, the shift mostly being from the medical orientation of diagnosis and therapy to the person-centered and context-oriented care (Borg et al., 2009). One way for professionals to embrace this shift in orientation is to focus on service users’ understandings and interpretations regarding the meanings and modes of emergence of crises, and their preferences in dealing with crises situations.
User’s experiences with help and support from CR/HT
85
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
Conclusion Individuals suffering from acute mental distress represent a heterogeneous group, and this need to be considered in service planning and team development. Although there is a great variety of CR/HT models instituted in the US and many European countries, this review identified three themes that represent positive help perceived to be important to service users. These are (a) the accessibility and availability of help and support in the home context, (b) being understood as ‘‘normal’’ human beings through respectful listening, and (c) dealing with crises in everyday life contexts. Although these key findings reveal the major features of service user satisfaction with CR/HT, the literature is lacking in specifying what conditions and processes influence ‘‘best ways of helping’’ or how existing systems and organizations foster or hinder service users from attaining the most help in CR/HT services. The results of this review suggest that there is a need to investigate the nature of processes that are inherent in practice that may impact on service user outcomes. It is especially important to study what processes and practices impact on the three key features of the findings. While the general structure, organization, and service schemata may be standardized for CR/HT teams, it is the actual practice of services that can be varied to result in service user outcomes. Therefore, the areas that require further research are, for example, (a) how the professionals’ philosophies of practice influence their approaches within CR/HT teams, (b) what sort of communication and interaction strategies are most effective in producing the most effective help, (c) how service users’ assumptions, expectations, and meanings influence the service process and outcomes, and (d) what processes are needed to produce the best outcomes given the dynamics among service users, their social networks, and the professionals as well as with the tertiary service providers? As CR/HT teams are in its formative stage, it is necessary to enrich the knowledge base to establish them in most effective ways. Acknowledgements ‘‘Crisis Resolution and Home Treatment in Community Mental Health Service’’ for which Dr Hesook Suzie Kim is the project director and Drs Marit Borg and Bengt Karlsson are the principal researchers. This project is funded by the Research Council of Norway from 2007 to 2011. We acknowledge the support and assistance provided by various staff members of Buskerud University College in carrying out this research project. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper. References Ampelas, J.F., Robin, M., Caria, A., Basbous, I., Rakowski, F., Mallat, V., et al. (2005). [Patient and their relatives’ satisfaction regarding a home-based crisis intervention provided by a mobile crisis team]. Encephale, 31(2), 127– 141. Andersen, R. (1995). Revisiting the behavioral model and access to medical care: Does it matter? Journal of Health and Social Behavior, 36(1), 1–10. Beresford, P. (2005). Developing self-defined social approaches to madness and distress. In S. Ramon & J.E. Williams (Eds.), Mental health at the crossroads: The promise of the psychosocial approach. Aldershot: Ashgate. Boevink, W. (2005). From being a disorder to dealing with life: An experiential exploration of the association between trauma and psychosis. Schizophrenia Bulletin, 32(1), 17–19. Borg, M. (2007). The nature of recovery as lived in everyday life: Perspectives of individuals recovering from severe mental health problems. University of Science and Technology, Trondheim.
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
86
M. G. Winness et al.
Borg, M., & Davidson, L. (2008). The nature of recovery as lived in everyday experience. Journal of Mental Health, 17(2), 129–140. Borg, M., Karlsson, B., Tandora, J., & Davidson, L. (2009). Person-centred practices in psychiatric rehabilitation – what does this mean? The Israel Journal of Psychiatry and Related Sciences, 46, 84–93. Bridgett, C., & Polak, P. (2003). Social systems intervention and crisis resolution. Part 1: Assessment. Advances in Psychiatric Treatment, 9, 424–431. Brimblecome, N. (2001). Acute mental health care in the community: Intensive home treatment. London: Whurr Publishers Ltd. Caplan, G. (1964). Principles of primary prevention. New York: Basic Books. Clark, F., Hudson, J., Khattak, S., McKinley, C., Nahal, J., & Thejopal, R. (2007). Helping people through mental health crisis: The role of Crisis Resolution and Home Treatment services: National Audit office (NAO), UK. Coleman, M., Donnelly, P., Davies, A., & Brace, P. (1998). Evaluating intensive support in community mental health care. Mental Health Nursing, 18(5), 8–11. Cullberg, J. (1978). Mennesker i krise og utvikling. Oslo: Aschehoug. Cullberg, J. (1999). Dynamisk psykiatri. Oslo: Aschehoug. Deegan, P.E. (1997). Recovery as a journey of the heart. In L. Spanoil & M. Koehler (Eds.), Psychological and social aspects of psychiatric disability (pp. 74–83). Boston: Boston University Center for Psychiatric Rehabilitation. Fitzsimons, S., & Fuller, R. (2002). Empowerment and its implications for clinical practice in mental health: A review. Journal of Mental Health, 11, 481–499. Foucault, M. (1967). Madness and civilisation: A history of insanity in the age of reason. London: Tavistock/ Routledge. Foucault, M. (1973). The birth of the clinic: An archaeology of medical perception. London: Tavistock. Goldsack, S., Reet, M., Lapsley, H., & Gingel, M. (2005). Experiencing a recovery-oriented acute mental health service: Home based treatment from the perspective of service users, their family and mental healt professionals. Wellington: Mental Health Commission. Heath, D. (2005). Home treatment for acute mental disorders – an alternative to hospitalization. New York: Routledge. Hopkins, C., Deltodesco, D., & Wasley, S. (2002). Intervening safely in a crisis. Mental Health Nursing, 22(4), 18–21. Hopkins, C., & Niemiec, S. (2006). The development of an evaluation questionnaire for the Newcastle Crisis Assessment and Home Treatment Service: Finding a way to include the voices of service users. Journal of Psychiatric And Mental Health Nursing, 13(1), 40–47. Hopkins, C., & Niemiec, S. (2007). Mental health crisis at home: Service user perspectives on what helps and what hinders. Journal of Psychiatric And Mental Health Nursing, 14(3), 310–318. Johnson, S. (2007). Crisis resolution and intensive home treatment teams. Psychiatry, 6(8), 339–342. Johnson, S., Nolan, F., Hoult, J., White, I.R., Bebbington, P., Sandor, A., et al. (2005a). Outcomes of crises before and after introduction of a crisis resolution team. British Journal of Psychiatry, 187, 68–75. Johnson, S., Nolan, F., Pilling, S., Sandor, A., Hoult, J., McKenzie, N., et al. (2005b). Randomised controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. British Medical Journal, 331(7517), 599. Joy, C.B., Adams, C.E., & Rice, K. (2006). Crisis intervention for people with severe mental illnesses. Cochrane Database of Systematic Reviews (Online) (4), CD001087. Kalucy, R., Thomas, L., Lia, B., Slattery, T., & Norris, D. (2004). Managing increased demand for mental health services in a public hospital emergency department: A trial of ‘Hospital-in-the-Home’ for mental health consumers. International Journal of Mental Health Nursing, 13(4), 275–281. Karlsson, B., Borg, M., & Kim, H.S. (2008). From good intentions to real life: Introducing crisis resolution teams in Norway. Nursing Inquiry, 15(3), 206–215. Karlsson, B., & Hultberg, K. (2007). Brukererfaringer med kriseintervensjon i eget hjem. Tidsskrift for Norsk Psykologforening, 7, 900–905. Khan, I., & Pillay, K. (2003). Users’ attitudes towards home and hospital treatment: A comparative study between South Asian and white residents of the British Isles. Journal of Psychiatric & Mental Health Nursing, 10(2), 137–146. Kogstad, R. (2009). Protecting mental health clients’ dignity - the importance of legal control. International Journal of Law and Psychiatry, 32, 383–391. Laugharne, R., & Priebe, A.S. (2006). Trust, choice and power in mental health. Social Psychiatry & Psychiatric Epidemiology, 41, 843–852.
J Ment Health Downloaded from informahealthcare.com by Kings College London on 04/21/10 For personal use only.
User’s experiences with help and support from CR/HT
87
Morgan, S., & Hunte, K. (2008). One foot in the door. Mental Health Today (Brighton, England), 32–35. Onken, S., Craig, C., Ridgway, P., Ralph, R., & Cook, J. (2007). An analysis of the definitions and elements of recovery: A review of the literature. Psychiatric Rehabilitation Journal, 3(1), 9–22. Rappaport, J. (1987). Terms of empowerment/exemplar of prevention: Toward a theory of community psychology. American Journal of Community Psychology, 15, 121–148. Read, J. (2004). Does ‘schizophrenia’ exist? Reliability and validity. In J. Read, L. Mosher & R. Bental (Eds.), Models of madness: Psychological, social and biological approaches to schizophrenia. New York: Brunner-Routledge. Rijckmans, M.J.N., Bongers, I.M.B., & Garetsen Van de Goor, I.A.M. (2007). A client’s perspective on demandoriented and demand-driven health care. International Journal of Social Psychiatry, 53, 48–62. Robin, M., Bronchard, M., & Kannas, S. (2008). Ambulatory care provision versus first admission to psychiatric hospital: 5 years follow up. Social Psychiatry and Psychiatric Epidemiology, 43(6), 498–506. Ruggeri, M., Salvi, G., Perwanger, V., Phelan, M., Pellegrini, N., & Parabiaghi, A. (2006). Satisfaction with community and hospital-based emergency services amongst severely mentally ill service users: A comparison study in South-Verona and South-London. Social Psychiatry & Psychiatric Epidemiology, 41(4), 302–309. Scott, R.L. (2000). Evaluation of a mobile crisis program: Effectiveness, efficiency, and consumer satisfaction. Psychiatric Services, 51(9), 1153–1156. Sha, M.O. (2006). ‘‘You have come to the right place. . ..’’ Mobile Acute Services at Mental Health Centers. IS-1358. Sosial-og helsedirektoratet, Oslo, Norway. Szasz, T.S. (1974). The myth of mental illness: Foundations of a theory of personal conduct. New York: Harper and Row. Thornicroft, G., & Tansella, M. (2004). Components of a modern mental health service: A pragmatic balance of community and hospital care: Overview of systematic evidence. The British Journal of Psychiatry, 185(4), 283– 290. Whittle, P., & Mitchell, S. (1997). Community alternatives project: An evaluation of a community-based acute psychiatric team providing alternatives to admission. Journal of Mental Health, 6(4), 417–427. Wilson, A., & Beresford, P. (2002). Madness, distress and post-modernity: Putting the record straight. In M. Corker & T. Shakespeare (Eds.), Disability/postmodernity: Embodying disability theory. London: Continuum.
