The best way to provide community-based mental health services is through multi-disciplinary teams that use different skills and ideas to collectively solve problems of treatment, management, support and care. Unfortunately, evidence shows that poor communication is undermining this.
Recent research1 considered whether these communication difficulties were due to a lack of an accepted definition of mental disorder. As a result, different groups within multi-disciplinary teams may work with people with mental health problems in very diverse ways. In practice, these different understandings – or models – might interfere with decision-making as teams may have differing assumptions that create misunderstandings.
The study identified six models of mental disorder: medical (organic), social, cognitive behavioural, psychotherapeutic, family, and conspiratorial. One hundred respondents – including psychiatrists, community psychiatric nurses, approved social workers, people diagnosed with long-term schizophrenia, and informal carers – were interviewed. This involved questions about a case study of “Tom” whose behaviour suggests he may have schizophrenia. The questions were aimed at distinguishing the models; for example, “What do you think caused Tom to behave like this?” Each respondent was also asked to recall two critical incidents involving interagency co-operation: one successful, one less so.
The results showed clear differences between practitioner groups: psychiatrists and community psychiatric nurses favoured a medical interpretation of mental disorder (91.3 per cent and 60.8 per cent respectively); while social workers showed strong support for the social and psychotherapeutic models (47.5 per cent and 36.7 per cent respectively). A sub-sample of patients rejected the medical in preference for a psychotherapeutic interpretation of their schizophrenia (46.8 per cent). In the case of informal carers, support is shown for the medical and family model (39.2 per cent and 24.2 per cent respectively).
Overall, the findings show that each group implicitly supports a model that appears to be explicitly linked to their training and experiences of mental disorder.
The results from the critical incident questions suggest that decision-making promotes a medical interpretation of mental disorder. Moreover, the power of medicine continues to dominate despite the fact that it is more often social support that service users need.
The study argues that while all groups recognise that medicine is socially valued, alternative models compete unsuccessfully for recognition alongside the traditional medical approach. This situation promotes working structures and practices that generate conflict and misunderstanding, and restricts options for both practitioners and service users.
Practitioners, service users and informal carers should be able to work together as a multi-agency team, which has learned to recognise and respect differences in models. The study suggests that this will only be achieved through multi-agency training around models “consciousness-raising”.
Over time, the balance of power within the decision-making process should be redefined. This does not mean that the purpose and role of medicine would be destroyed. Instead, team decisions regarding the treatment, management and support or care of a service user’s specific community-based mental health needs should be reached through an informed consideration of a range of options that may or may not include medical solutions.
1 A Colombo, G Bendelow, B Fulford and S Williams, “Evaluating the influence of implicit models of mental disorder on processes of shared decision making within community-based multi-disciplinary teams,” International Journal of Social Science and Medicine, Vol.56, 2003
Anthony Colombo is senior lecturer in social work, School of Health and Social Sciences, Coventry University.