Psychological interventions - 3

In the third of a three-part article, four trainee psychologists, Luisa Eminyan, Louisa Houlton, Fleur Mifsud Bons and Antonella Mizzi, compare the psychological services in the UK and Malta.

Our visit to the Oxfordshire and Buckinghamshire Mental Health Partnership NHS Trust in the UK provided us with the opportunity to learn more about the country's mental health care system and on how the provision of these services is managed. The present target is for service users to get easy access to more effective primary care with support from specialised care wherever necessary.

The mental health services in the NHS are divided into four tiers or levels of intervention with the primary point of contact for people with psychological or mental health difficulties being the General Practitioner. This is also the case in Malta where many GPs provide a valued community mental health service. Locally, however, this important resource could be capitalised on and developed further so as to provide a more holistic intervention. In the UK, for example, it is common practice for psychologists to work together with the GP to provide an initial psychological intervention to persons who require a minimal level of treatment, as the case may be for persons suffering from anxiety or depressive symptoms.

At this point, referrals for group therapy and/or support groups are made. Self-help booklets about many common mental health conditions are also distributed and give useful insights and tips on how to cope or manage the problem. For some people this level of intervention is sufficient and thus, the Tier 1 service acts as a filter to the secondary level services within the NHS, cutting down on waiting lists and delays in service provision.

With the increasing numbers of trained psychologists in Malta, this is a system that can be implemented locally. Improving on early intervention services would help in the prevention of future problems, to reduce the use of medication and relieve the caseload from the already saturated out-patient psychiatric services.

While Oxford City still has a strong medical influence, there is a move away from hospitalisation towards more community-based services together with a shift from diagnosis towards assessment of needs. The UK National Service Framework for Mental Health (DOH, 1999) places increasing importance on community mental health care because service users are more likely to stay in contact with community rather than hospital-based services and are more likely to accept treatment. This in turn promotes and supports better self-care. It was interesting to learn, for example, that generic workers in community teams focus more on engagement of clients rather than on therapeutic intervention per se. The belief is that clients engaged in the service are more motivated to attend for therapy and benefit more.

Community mental health teams in the NHS, which are multi-disciplinary and include a psychiatrist, psychologist, psychiatric nurses and generic mental health workers, are commonly found and constitute the Tier 2 services. At this secondary level, the thorough needs assessment is also carried out leading to a comprehensive clinical formulation. The assessment is holistic and adopts a bio-psychosocial perspective allowing for referrals to appropriate services and reducing the risk of accessing futile services. Persons are either offered further generic community services, time-limited individual psychotherapy or referred to more specialised tertiary services depending on the severity of the risks involved.

In the UK, the move towards community care has also been possible as a result of a variety of specialised services that cater for different mental health needs. We had the opportunity to visit several of these, including the Eating Disorders Service, Forensic Services, Specialist Community Addictions Service and the Complex Needs Service to name a few.

In the local context, the need for specialised intervention is particularly felt by the service users as well as the professionals in the field. This is certainly the case for eating disorders, young offenders as well as child and adolescent mental health where the services currently available are overloaded and treatment offered is limited making them less effective. In keeping with recent research in the field, the National Service Framework for Children (DOH, 2004) has set a clear direction for the future of health services for children. It called for integrated services using common processes, especially for assessment and effectively targeted, community-based, specialist services. Examples of such services, which would be considered innovative locally, include the Attach Team and the Mental Health Infant Parent Teams which are outreach teams that intervene to improve parent-child relationship at an early stage thus, preventing further problems and safeguarding children's mental health.

It's important to note that while specialised services may be effective at targeting different forms of long standing mental health difficulties, the implication is also that there are specific sets of criteria that need to be met for admission to such services. The result of this is that some persons whose difficulties are too severe and cannot be treated by the generic services, also have needs that are too complex to be dealt with by specialised services. Similarly, persons with co-morbid mental health difficulties may be required to seek treatment from two distinct services which may result in a fragmented treatment.

We had the opportunity to be exposed to a different ethos underlying the mental health service provision. The emphasis on client empowerment is strongly felt running alongside a strong anti-stigmatisation movement. Many of the services we visited adopted a more collaborative approach with their clients. This approach challenges the 'expert' position and proposes one in which the therapist or practitioner takes a learning position through facilitating and sustaining dialogue with the client (Anderson, 2001). The best operative example we witnessed is the Complex Needs Unit, a therapeutic community for persons with personality disorders; although such labels are consciously being avoided. Service users are simply referred to as 'community members' and the term personality disorder is reframed as a developmental consequence of disempowering experiences, rather than an untreatable life-long disability.

The aim of the treatment is to offer the service users the choice of forming a suitable network of therapeutic and supportive relationships which is tailored to their own needs and stage of development, in full partnership with those delivering the service. On the other hand, one must also consider that treatment in therapeutic communities takes time - typically around six to twelve months which increases the possibility that patients will leave prematurely (Lees, Manning, Rawlings, 2004).

This three-week experience has certainly opened our eyes further to a greater appreciation of the influence of the contextual framework in which we work: The cultural, political and agency factors which impact on the provision of our practice. Furthermore, it was particularly enriching for us, as trainee psychologists, because it exposed us to new ways of working and standards of practice that will inform our work. Being introduced to a number of specialised and innovative services has led us to reflect on diverse models of practice which can also be translated into the local setting.

The group of trainee clinical and counselling psychologists carried out a three-week placement in the UK as part of the Community Vocational Training Programme of the Leonardo da Vinci EU-funded programmes.

(Concluded)