Cameron is a Canadian PhD student at the Department of Global Health & Social Medicine. He is currently working on an ethnography of home treatment in psychiatry. Cameron has spent a year immersed in a Psychiatric Home Treatment Team in South London working alongside nurses, support workers and psychiatrists in the community. His work has brought him into the homes of service users in South London and is enriched by interviews with service users and team members.
Before joining GHSM at King’s College London, he completed a MSc in Biomedicine, Bioscience and Society at the London School of Economics and Political Science. Prior to this he completed a Bachelor of Arts (Hons.) in Sociology at Trent University. He also spent time in a Bachelor of Social Work program at Laurentian University.
Hello, I'm Nigel Warburton and Joining me today is Cameron Spence, A PhD Candidate in the department of Global Health and Social Medicine at King's College London. The topic we are going to talk about is psychiatric home treatment. Could we just begin by spelling out what that is?
Home treatment is basically a psychiatric team consisting of psychiatrists nurses support workers and social workers. They go to the home once in the morning and once at night and they administer medication, they talk to the patient, they do a bit of supportive counseling and it usually lasts between one week and three or four months at max.
And so the idea is that your visiting someone who's got psychiatric problems in their own home, presumably that has cost implications, it must be cheaper than that person being within a hospital ward for instance?
It's certainly cheaper than being within a hospital ward. I mean home treatment is used a lot as a deferral service away from the wards, so if a person is not quite as ill as they should be to go in a ward, home treatment will pick them up and work with them.
Is this something that's found across the world or is it unique to Britain?
It's almost unique to Britain, it's found in a couple of Scandinavian countries but for the most part Britain is probably the largest user of home treatment. And home treatment extends through England, Wales, Northern Ireland and Scotland.
So that's slightly bizarre as you would think it's an obvious solution to somebody with not particularly severe psychiatric problems to go and visit them
Well, I mean, it is an obvious solution but it's also not a well evidenced solution, in 2000 the government brought home treatment in as a national policy and at the time there was very thin evidence that it was one, better than the wards or two, better than the community mental health teams. One of the big factors is that it reduces the use of beds and it reduces the cost of care. That's probably the main reason that they brought it in.
And so what's the history of this, is it something, you mentioned it was brought in as a national policy in 2000, but it must have had a prehistory.
The prehistory dates back to the 1930's in Amsterdam and during the great depression they decided that it was just not affordable to keep people in asylums in Amsterdam. So they tasked a psychiatrist with figuring out another way. The other way was we'll treat people in their homes and hopefully that will be as good. It turned out to be a success and it's still used in Amsterdam.
So pre 1930 everybody with psychiatric problems who was diagnosed would end up in an asylum?
Not technically, there were some other programs that went on. Going all the way back to the 1600's you could look at Gheel in Belgium as a residential treatment center where people were boarded out to families and the families were paid to keep them and they loved them like there own. It was a great place for people to go. Of course during the 1600's all the way up to present day it was rich people who would drop their sons and daughters off and leave them there, still not a great life. For most other people it was the asylums until the 1930's. Then you have home treatment that develops across the world, some in the United States, one in Canada and one in Australia, all though these ones don't continue. But the major one was the ‘Training in Community Living’ center in Madison, Wisconsin. They took the model that was kind of around for Amsterdam and they turned that into more of a training people to live in the community program.
I'm really interested in how you go about researching this topic. How do you find out about psychiatric home treatment?
It's not really a very well studied phenomenon so the best way to go about doing it is not to collect quantitative data, other people do that and it doesn't really show what happens. A lot of the psychiatric research says we treat people in the home but what is treating people in the home? what do they do when they enter the home? So the best way to go about doing this is an ethnography, which is by basically going out and being part of the team, participating and observing what's going on and also interviewing patients and interviewing home treatment members.
And how often do you go out on these visits?
I do four to five days a week with the home treatment team. I go out on visits everyday, I see maybe two to three people a day and I will hopefully see those same people about 5 times. I also take part in home treatment meetings, I take part in clinical reviews, I take part in trust meetings when I can and I also occasionally attend Mental Health Act assessments.
So you've become almost a participant observer?
I have become a participant observer and in some ways I've become a member of the team. You know when things get a little more intense, because you can only go out with two people in each home because let's face it this is London and the homes are small. And when things get intense I have to participate.
And how do you record what happens?
When I'm in the team base I write everything down in note books. When I'm outside of the team base I'm basically using my memory as a tape recorder. I'm trying to intensely take in everything around me and then once I get back to the team base I immediately type up between three and five thousand words a day.
That's incredibly labour intensive.
It is, but no one said a PhD would be fun.
You've been doing this for a while now and what have you noticed in relation to austerity because we are in a situation where all kinds of cuts are being made to services and this must have an impact on what your doing.
When it comes to home treatment, you look through the history and you basically see that it's always attached to an economic logic right, it saves the use of beds and it saves money and that extends all the way through to 2000 when the home treatment teams came into effect and at that point they started running down the number of beds that the services had. So between 1998 and 2012 bed levels plummeted by 39 percent. And now post 2008 financial crisis the conservative government has introduced policies of austerity and what those polices have done is basically you have social care cuts, so 30,000 people who suffer from mental health conditions have lost any social care support, you have changes to the benefits system that have increased benefits sanctions, so that's when benefits are removed for a period of time because the person who received the benefits wasn't able to do whatever they wanted them to do, usually visit a job center and those sanctions have gone up 668% for people with mental health conditions. So as a consequence the benefits sanctions going up by 668% you have people who go into crisis and end up either in the ward or with home treatment teams, so this puts an increased pressure on home treatment teams and an increased pressure on the wards. You also have NHS cuts which are basically causing havoc in the community mental health team. They used to go out and visit people in their homes once a week but now they're seeing people in the team base every two weeks. You also have the development of teams called low intensity treatment teams which is basically a euphemism for we'll see you once a month and check your bloods and so what happens is, it's not like the old mental health system right, the ward is not a place where you go for respite, it's not an asylum anymore. What it is is a place where you can go get intensive treatment for 7-14 days based on a triage model and then your out with home treatment team. And so what you see is a speeding up of care.
Can the system cope with this increased number of people making demands on it.
It can cope and the way that it is coping that the trust is reorganising the way they use home treatment. And so by drawing people off the wards and moving people out through home treatment as quick as possible they are changing the model of care but the thing is that they are changing the model of care without having any new psychopharmacuetical drugs, without having anything new whatsoever. They're just tooling with the model of care and so what you get is a system that has high human costs to it. And those human costs come from the cuts to the system cuts to the benefits system a lack of proper housing and you know just the busyness of London and the fact that its not a times the best place to live.
That's quite a pessimistic view of something of which I know you think is a good system.
Home treatment is an excellent way to treat people, I mean let’s get that straight. It's much better than being in the ward. The wards back in the 90's were called atherapeutic and now partly because of home treatment scooping off the patients who aren't super unwell, those wards have become even more of a place where you don't want to go. I mean I was out with a home treatment team member and we had a very depressed woman who was very anxious and jumping at noises and she said well, you know take me to hospital and we had to basically tell her that hospitals not a nice place for depressed people because the rate of psychosis and the disruption in the ward because people who are very unwell are going there doesn't make it a place of asylum anymore. So home treatment is the best possible service you can get, at the same time home treatment ends up holding on to a lot of risk. There are studies that show that home treatment isn't particularly good at preventing suicide but it is good at containing patients and how they contain patients is basically by showing up once a day in the morning and showing up once a day in the night and that allows the person to know that, yes, there are people that are coming to talk to me, they are going to help me take my medication and I can plan my day around those things and it forces them to plan their day around those things, also funny enough home treatment can happen outside the home, they can be invited to come to the team base to see them and that’s another way to structure their day and so if you look at being on the ward compared to home treatment, home treatment you get to stay in your home, you get to see people who are going to talk to you twice a day, they'll help you take your medication, they'll council you a little bit and they may even help you with daily activities like washing clothes or reorganising your house, but at the same time patients are upset that you see different faces. It's not the same people that visit you every day. The team that I'm on has 35 different people and so any given day your going to see someone different. And they all have different styles and some are more beloved by patients than others but for the most part these are very caring people who are very good at their jobs.
How do you see the future of psychiatric treatment in the home, both realistically, what’s going to happen. But also ideally what would you like to happen.
The future of psychiatric home treatment is more of it. It's going to be more and more a crucial part of the system. It's already a fulcrum between the ward and the community mental health teams and it's just going to grow. it is the safety net for those teams and so when cuts happen to those teams and something bad happens home treatment is often there to scoop patients up. But at the same time treatment is speeding up and people are starting to go through the system faster and so what ends up happening is that people can often be taken for a ride. So instead of advocating for the treatment they need and the treatment they want they end up going along for whatever treatment comes their way. Which is a problem. And so I think the best thing for home treatment to do would be to training patients or teach patients how to advocate for themselves, so do you need psychological therapy, yes, you need to ask for psychological therapy. If they can ask and if they can advocate for themselves, they can get the services they need in a timely manner and also put pressure on the system so that the government is aware that they need more capacity and they won't just do with the capacity they have.
Cameron Spence, thank you very much.