Mental health: solutions to complex care needs
Submitting Institution
Birmingham City UniversityUnit of Assessment
Allied Health Professions, Dentistry, Nursing and PharmacySummary Impact Type
SocietalResearch Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Summary of the impact
The Centre For Community Mental Health (CCMH) is a research team within
the Centre for Health
and Social Care (CHSCR). CCMH develops and supports research that reduces
stigma and social
exclusion and which empowers people with mental health problems to lead
fulfilling lives in their
own communities. The impact of this research has challenged prevailing
beliefs and practices and
led directly to changes in practice, organisational processes and service
design across the world.
Our studies of voice hearing, in adults and children, have shown that it
may not always be
associated with mental illness and that cognitive behavioural therapy is
effective for many people.
Our work has led to the development of the Hearing Voices Movement and the
International
Hearing Voices Network, which now spans 22 countries and which enables
people who hear
voices to find bespoke solutions and lead normal lives.
The impact of our work on community-based approaches to the management of
acute and long
term mental ill health led, first, to the development of assertive
outreach and crisis resolution teams
that reduced hospital admissions by treating people at home; second, our
work has led directly to
service redesign in many different countries.
Our studies of special and underserved social groups in relation to
mental ill health have
demonstrated the multiple barriers to services that many people
experience. The impact of these
studies has included changes in organisational practices to promote
greater engagement with
service users.
Underpinning research
Long term mental health problems affect large numbers of people worldwide
and often have
profound effects on their daily lives, dignity, liberty and human rights.
CCMH is founded on a
compassionate, patient-focused approach to researching mental health by
bringing together
academics from this University and other HEIs, those who use and work in
mental health services,
community and international organisations to research key issues in mental
health as a basis for
change. The outcomes of CCMH research have made a contribution not only to
knowledge, but
also to practice and patient experience in the UK and across the world.
Pioneering work initiated by Professor Marius Romme has challenged the
established view that
voice hearing is always symptomatic of serious mental disorders such as
schizophrenia.
Acceptance of this explanation limited the exploration of alternative
approaches that might help
voice hearers live functioning, settled and fulfilling lives. The initial
research, in 1989, demonstrated
that voice hearing was more common that previously assumed and that
hearing voices was not
always a sign of mental illness. This led to the development of the
Hearing Voices Movement.
Professor Romme joined the CCMH in 2000 where, in collaboration with
Professor Mervyn Morris
and Sandra Escher, an Honorary Research Fellow, further research was
undertaken to adapt the
Maastricht Voices Interview (MIK) for use with children (REF1). An RCT
evaluated the use of group
cognitive behavioural therapy (CBT) for voice hearers and concluded that
this therapy was
effective in the treatment of auditory hallucination, specifically
reducing voice frequency and
perceived voice power in comparison to normal psychiatric treatment
(REF2). Application of this
new knowledge about voice hearing was tested in the preparation of mental
health professionals;
findings showed that they were able to integrate this with their existing
skills and knowledge but still
had to address organisational resistance to change (REF3).
In the late 1990s, in line with the National Service Framework for Mental
Health (DH 1999) which
emphasised the political importance of modernising mental health services,
the CCMH, in
collaboration with the North Birmingham Mental Health NHS Trust,
researched and pioneered the
Birmingham Model of Community Mental Health (BMCMH). The Trust was led by
Professor
Sashidharan who was then a Visiting Professor at CCMH; Professor
Marcellino Smyth edited the
first detailed guidelines which were published jointly by the National
Institute for Mental Health in
England and the University in 2007. The focus of the model was on recovery
and inclusion;
reducing hospital admissions by averting crises and treating people with
acute mental illness at
home or in the community. Evaluation of the initial service redesign,
which was funded by the
Sainsbury Centre for Mental Health (REF4), concluded that `the North
Birmingham approach is an
important example of an attempt to develop a total district service
model. Its three layer team
configuration is an important and fascinating experiment'. As
Director of the CCMH, Professor
Morris has driven the advance and uptake of the BMCMH approach and has
extended its
application to health services across the world. For example, as Visiting
Professor at UC Buskerud
in Norway, he provided leadership and expert advice in the construction of
tools to develop an in-depth
understanding of variations in the structures and processes required for
crisis resolution
(REF5).
A growing body of evidence indicates that members of certain social
groups have received little
attention from researchers in the mental health field. Members of these
groups are, frequently,
underserved by mental health services and socially excluded. The CCMH
works with a wide range
of community and statutory organisations and has developed a portfolio of
studies that examine
the experiences and particular needs of a number a different groups. These
include recent black
African migrants (Professor Fatemeh Rabiee-Khan), Irish migrants
(Professor Paula McGee) and
members of the defence services (Professor Alan Finnegan). Studies in this
portfolio challenge
prevailing stereotypes and reveal the multiple obstacles that many members
of these groups
encounter when attempting to obtain help (REF6).
References to the research
REF1. Escher, S., Morris, M., Delespaul, J., Romme, M. (2004)
Determinants of outcome in the
pathways through care for children hearing voices. International
Journal of Social Welfare 13, 208-222.
REF2. McLeod, T., Morris, M., Birchwood, M., Dovey, A. (2007) Cognitive
Behavioural Therapy
based group work with voice hearers (I) & (II). British Journal of
Nursing. 16, 4, 248-252
REF3. Chapman, J. & Morris, M. (2011) Post-qualifying students'
experiences of implementing
skills acquired form a "hearing voices" module into routine clinical
practice. The Journal of Mental
Health Training, Education and Practice. 6(2), 85-92.
REF4. Minghella, E., Ford, R., Freeman, T., Hoult, J., McGlynn, P &
O'Halloran, P. (1999) Open all
hours: 24-hour response for people with mental health emergencies;
London, The Sainsbury
Centre for Mental Health
REF5. Karlsson, B., Borg, M., Eklund M., and Kim, H.S. (2011) Profiles of
and practices in crisis
resolution and home treatment teams in Norway: a longitudinal survey
study, International Journal
of Mental Health Systems, 5:19 doi:10.1186/1752-4458-5-19
REF6. Finnegan, A, Finnegan, S, McGee, P, Ashford, R, Simpson, R., (2011)
Serving within the
British Army: research into mental health benefits. British Journal
of Nursing, 20(19),2156-61
Details of the impact
The impact of CCMH's research spans a number of different contexts and
there is overlap between
the three bodies of work outlined in section 2. For example, changes in
the understanding of voice
hearing have impacted on service redesign and the education of
professionals but also contributed
significantly to international developments in mental health. This new
understanding of voice
hearing has led directly to improvements in the lives of people who hear
voices by creating spaces
in multiple professional and public spheres, in which voice hearing can be
discussed openly and
without censure (S1); developing resources to inform and support both
those who hear voices and
those who attempt to help them (S1-3); and facilitating the development of
a wide range of
practical solutions that enable those who hear voices to cope and lead
fulfilling lives.
The nature and evidence of impact can be seen in the development of Intervoice,
the International
Hearing Voices Network, an interactive coalition of voice hearers, carers,
mental health
practitioners and academics, which aims to improve the lives of voice
hearers through education,
research and facilitating the development of practical solutions.
Intervoice's website is available to
anyone seeking information about voice hearing There are now national
networks in 22 countries
providing help, advice and support to those coping with voice hearing.
Intervoice is now managed
as an independent concern which acts as an umbrella organisation for the
national networks (S1).
Impact can also be seen in service re-design via CCMH's contributions to a
comprehensive
training package aimed at empowering mental health service users to become
expert patients,
able to provide peer support and training for others (S2). In addition,
other resources such as
Living with voices: 50 stories of recovery which presents an
analysis of individual experiences as a
basis for explaining why people hear voices, the importance of accepting
rather than dismissing
such experiences and the pathway to recovery (S3), has sold nearly 4000
copies since publication.
The book is recommended reading for students of mental health
professions, in a number of
universities, including Dublin City University, Kings College, the
University of London and the
University of York. Mental health organisations in the NHS have also drawn
on Professor Romme's
publications to produce local resources for those who hear voices. One
example is Hearing Voices,
a booklet published jointly by The Hive and the Scottish Association for
Mental Health which
recommends Living with Voices to patients and carers (S4). Other
resources based on this work
are available to patients, carers, professionals and the general public
through mental health
services. The book is also recommended by mental health organisations In
the USA and Australia
(S5).
The BMCMH was adopted by the Labour Government of 1997-2001 which
prioritised mental
health. The National Service Framework Mental Health emphasised the need
for early intervention,
assertive outreach, crisis resolution and carer support as essential
components of primary care
(S6, S7). Further evidence of the impact of the model can be seen in
exports to numerous other
countries, including Belgium and Norway, which are effected through
consultancy and advisory
services to governments and ministries seeking to modernise mental health
services in line with
the WHO action plan for mental health. Application of the BMCMH and the
approach to voice
hearing outlined above have proved appropriate and effective in societies
as diverse as Sri Lanka
and Norway in terms of service design and professional education. The
Director General of the
Belgium Health Ministry declared that `Professor Morris is one of the
most solicited experts from
abroad in this formation programme, his advice resulted in the
engagement of other experts from
Birmingham and in selecting the right beacon sites or learning places in
Birmingham and
elsewhere in the UK' (S8). Most recently, Professor Morris's
expertise was recognised and
solicited by the World Health Organisation which commissioned him to
develop a report (S9) and
he has now been invited to assist Vietnam to redesign community mental
health services in a
project attempting to address the plight of chained patients.
The impact of studies addressing the needs of members of special and
underserved social groups
is evident in many different spheres. One example is Birmingham and
Solihull Mental Health NHS
Foundation Trust in which CCMH's studies have been instrumental in
improving care for members
of black and other minority ethnic groups suffering with mental illness.
The Trust has changed its
practices to involve mental health service users from diverse backgrounds
at every level within the
organisation, including the Board of Governors and induction training for
new staff. Diversity issues
and cultural competency are now addressed routinely through staff
development (S10).
Sources to corroborate the impact
S1. Intervoice http://www.intervoiceonline.org/
S2. Training programme for people with experience in mental health crisis
to work as trainer and
peer supporter, available at
http://www.adam-europe.eu/prj/1871/prd/3/1/Curriculum_english%20i.pdf
(last accessed 19.11.13)
- PDF available
S3. Romme, M., Escher, S., Dillon, J., Corstens, D., and Morris, .M. Living
with voices: 50 stories
of recovery, Ross-on-Wye, PCCS Books.
S4. The Hive Hearing Voices, The Royal Edinburgh Hospital and The
Scottish Association of
Mental Health, available at
http://www.samh.org.uk/media/296074/hearing_voices_booklet__the_hive_.pdf(last accessed
10.09.2013) — PDF available
S5. Examples include Powys Mental Health Information and Participation
Service
http://powysmentalhealth.blogspot.co.uk/2013/04/top-mental-health-books-part-1.html
See also
Prahan Mission http://www.prahranmission.org.au/voices_vic_resources
and Hearing Voices USA
http://www.hearingvoicesusa.org/reading-list.html
S6. Department of Health, (1999) The National Service Framework
Mental Health London DH.
S7. Smyth, M. (2007) Ed. Crisis resolution and home treatment. NHMHE and
University of Central
England.
S8. Letter from Director General for the Organisation of Health Care
Establishments, (Federal
Public Service (FPS) Health, Food Chain Safety and Environment), Belgium
S9. WHO report on `Population and setting-based interventions for the
World Health Organisation
Western Pacific Regional Office'
S10. Letter from Director of Community Engagement and the Executive
Medical Director of
Birmingham and Solihull Mental Health Foundation Trust, England