MIND MOVES Tony BatesThe mental health service in Carlow is setting a headline for person-centred community care that addresses the needs of people in crisis in a highly integrated and creative way. At a time when many services are inadequate and failing to meet the needs of users, it represents an innovative approach and model of care that deserves all our attention.
In the wake of the 1984 national policy, Planning for the Future, mental health services began a process of de-institutionalisation. The vision of care described in this document emphasised integrated, holistic care, to be delivered in communities through a range of structures that would replace large institutions. Mental health services would become agents of social change, rather than offer shelter from social confusion.
People who had been hospitalised for years - with very little opportunity of recovery or re-integration with their own families or communities were gradually discharged. But staff felt threatened as beds closed and their traditional roles became redundant. Communities also felt threatened, as people with many residual mannerisms of institutional life were decanted into local housing without support or practical assistance. Institutions closed down as promised, but people often ended up ghettoised in facilities that quickly turned into mini-institutions.
However, the Carlow service has managed a transition to community-based care that has greatly reduced its bed usage, and cut the length of stay to a matter of days, but it has also evolved a system of community care teams, structures and expertise that respond to the real and practical needs of its users.
Only a fraction of the original 400 patients who were in long-stay beds remain in care, but it is important that these are not forgotten.
In Carlow, mental health services can be accessed as soon as a crisis arises. If you're in trouble, you will be seen, but the message of this service is: "You won't need an overnight bag."
Comprehensive multidisciplinary teams offering a range of medical and psychological therapies work closely to assess and address the needs of people in distress. The majority of crises that present are triggered by problems in a person's relationship with others and with their own inner lives, and the philosophy is to identify these difficulties and help an individual to engage with them in the context of where they live and work. Personal care plans are drawn up with users and dictate the service's response.
Some people may still need hospitalisation, but this is kept to an average of seven to 10 days, and used only to stabilise the individual's mental state before they embark on the serious business of addressing core issues in their lives. Another option available is the 'crisis house'. This is designed primarily for people who need time out when they find themselves in acute emotional distress, but it also offers transitional care to those who aren't quite ready to return home from hospital.
The Carlow crisis house is a detached corner residence with beautifully appointed gardens and patios. Nothing about it feels like an institution. While there is always a nurse on duty, and daily support from members of the multidisciplinary team who are working with individuals in the house, residents are free to come and go.
This house also offers respite care to those whose families and carers need a break. About six of the 14 rooms are available for respite. When I was there, one man in respite was taking a break from living with a sibling with whom he had a challenging relationship. The sibling was also a service user and had also availed of respite care in recent months. The Carlow service has negotiated with the local authority to separate the home where these two siblings live into two independent apartments. This practical intervention offers both people a way of living in their own home, in their local community, but with reduced friction and strain.
A section of the original hospital, refurbished with comfortable private rooms, a state-of-the-art kitchen and other training facilities, prepares people to return to fending for themselves in the community. Graduates may return to living in their own homes, or to one of seven community houses where they can make a home with others.
Daily follow-up is offered through the dedicated rehab teams, who visit residents in the community and who continue to work through with each of them the particular care plan drawn up with the team. The Carlow service has evolved in response to the needs of their particular client population and recognises that its structures may not fit the needs of every catchment.
What struck me most about it was the staff morale. Staff were proud of their service and believed it offered quality care to each person who engaged with it. Professional tensions and rivalry that are so common in other services have been minimal. Nursing staff retention has been 100 per cent since 1997. The Carlow service demonstrates that a different kind of service is possible when it is based on listening to the needs of its users, when users and providers work together, and when the unique talent of each member of the multidisciplinary team is valued and encouraged.
tbates@irish-times.ie
Dr Tony Bates is principal psychologist at St James's Hospital, Dublin.