Mental health: solutions to complex care needs

Submitting Institution

Birmingham City University

Unit of Assessment

Allied Health Professions, Dentistry, Nursing and Pharmacy

Summary Impact Type


Research Subject Area(s)

Medical and Health Sciences: Public Health and Health Services

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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

S2. Training programme for people with experience in mental health crisis to work as trainer and peer supporter, available at (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 accessed 10.09.2013) — PDF available

S5. Examples include Powys Mental Health Information and Participation Service See also Prahan Mission and Hearing Voices USA

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