Interventions and services for severe mental health needs

Citation

Hemmings, C. (2013), "Interventions and services for severe mental health needs", Advances in Mental Health and Intellectual Disabilities, Vol. 7 No. 3. https://doi.org/10.1108/amhid.2013.54207caa.001

Interventions and services for severe mental health needs

Article Type: Guest editorial From: Advances in Mental Health and Intellectual Disabilities, Volume 7, Issue 3

This special issue of Advances in Mental Health and Intellectual Disabilities focuses on services for people with intellectual disabilities and more severe mental health needs. There are two papers in this edition describing interventions rather than services but of the type that must be examined in the light of wider service provision considerations. Perera et al. describe the use of Community Treatment Orders (CTOs) in people with intellectual disabilities. CTOs were feared by many concerned for civil liberties, by clinicians, service users and by those outside services. However, it perhaps can be argued that they have not aroused as much controversy in practice as many had believed they would. The authors report interesting nuances in the use of CTOs in intellectual disability services, for example their use in people with autistic spectrum disorders. It seems from this study that CTOs may still be being under used compared to the wider population. It would be of great interest to see further such research, for example to study whether CTOs have caused a reduction in the amount of guardianship orders or altered admission rates or use of other Mental Health Act sections. Hemmings et al. then describe the use of portable crisis information as an intervention for people with intellectual disabilities and severe mental health problems. This paper links with much wider issues of emergency service provision for people with intellectual disabilities and mental health problems and the difficulties experienced by so-called “mainstream services” in providing care for this specific service user group. Barr (2011) has previously cautioned however about the use of the term “mainstream” by specialist intellectual disability services. He noted that it has often been used pejoratively to describe deficiencies in understanding, knowledge and care. Yet stigma, like racism, can operate in many directions. We are all probably familiar with the negative attitudes towards generic services and staff found among many people working in intellectual disability services. Some specialist intellectual disability clinicians, even when employed by mental health trusts, still have stigmatising attitudes towards mental health care and mental health services. This stigma has undoubtedly contributed to some problematic delays in progressing mental health care for people with intellectual disabilities, for example with the implementation of the Care Programme Approach.

Two papers in this issue consider the views of carers. Emery et al. provide crucial knowledge of the perspectives of carers. Even though the experience of telling their “story” may well be therapeutic, in general carers tend to be strongly pragmatic and only wish to be consulted about their views if those views are really going make a difference to practice. The authors’ descriptions of the methods they used to engage carers and to elicit their opinions will surely be of great interest to others seeking to include carers. The findings could be used to fine tune methods of engagement and to ensure that carers’ views are effectively implemented. Inwang et al. continue the theme of the carers’ perspectives using concepts developed in medical anthropology. In particular this paper draws on the thinking of Arthur Kleinman who has been one of the most inspirational writers of health care in recent decades. In particular Kleinman noted the obsession with technological progress when the single greatest leap forward in health care would occur if existing treatments could be applied more effectively, for example through improved compliance. Inwang et al. describe how the simple elicitation of the carers and clinicians’ explanatory models using a structured short list of questions can be used to compare different perceptions. This paper shows how this process strengthens the therapeutic alliance although it needs confidence from clinicians to acknowledge any differences when they occur.

Finally two papers consider the overview of services for this dually disadvantaged service user group. Sheehan and Paschos review the evidence base for the many varying different service models in existence. Although local flexibility and responsiveness are important it is unlikely that these are all just as good as each other. It is likely that differences in how services are configured and delivered for people with intellectual disabilities and mental health problems makes key differences to outcomes but Sheehan and Paschos show that we just do not have the evidence yet on which to decide. Hemmings and Al-Sheikh report their study of expert opinions into how key service components should be implemented. There is often a sense of dissatisfaction with current service provision, particularly from generic services and with crisis responses. Although the experts were firmly grounded as to the likelihood of any new resources for specialist service development, they were keen to work better with generic (or “mainstream”) services.

In generic mental health there already has been much discussion about where the “heartland” lies (Goodwin and Geddes, 2007). The core of severe mental health problems in people with intellectual disabilities can sometimes be overlooked as a priority for development when considering other areas such as autism and “neuropsychiatry” which are often seen as more alluring. It is important to adapt and modernize specialist intellectual disability services whilst having a strong sense that providing care for people with severe mental health problems is what its clinicians are either trained, or need to be trained, to do. It is important that clinicians can assess and treat mental health problems in the context of intellectual disabilities, not just one or the other. As Flynn (2010) has previously written, providing optimal care for people with intellectual disabilities and mental health problems will entail specialist intellectual disability services working differently and their staff offering to do more to assist their colleagues in generic mental health care. If they neglect to attend to the core severe mental health needs of their service users or attempt to hand the role to others, specialist clinicians may either find themselves in smaller and smaller niches or cherry-pick themselves out of occupational existence. Far more importantly people with intellectual disabilities will not have their severe mental health needs addressed.

Colin Hemmings