Published: 06/05/2004, Volume II4, No. 5904 Page 29

Jim McCourt on resolving the confused roles of community mental health teams

Community mental health teams remain the hub at the centre of the mental health wheel: unwanted and unfashionable, indefinable yet indispensable. They test the boundaries and effectiveness of the mental health system to the full and are the focal point for major dilemmas.

Because of the apparent intractability of such problems, and the poor regard in which teams are held, there is a danger that we shy away from tackling them.However, in avoiding the challenges posed by CMHTs, we lose a crucial opportunity to consider fundamental questions about mental healthcare, and only prolong divisions and splits.

The first area of difficulty for such teams concerns the nature of their core business. Incredibly, this is not clear. There is still no universal agreement on what mental illness actually means.

Biological, relational and social models co-exist or clash. The global term of severe and enduring mental illness is open to diverse interpretation. A wide range of clients and problems are referred to CMHTs, defying easy categorisation: a situation reflecting societal confusion over the understanding and definition of mental illness.

Arising from this first conundrum, the second area of difficulty concerns the clinical aims of CMHTs. The first of these is risk management - preventing clients from harming themselves or others or becoming a public nuisance.

The second aim is to manage or care for people diagnosed as having long-term psychiatric difficulties, not necessarily with a view to them getting better, but keeping them functioning at an optimum level. However, an increasingly prominent third aim is to help people recover from mental upset.

These three aims reflect different philosophies and are not necessarily congruent - they may be tangential, or even in conflict. The fact that they can co-exist simultaneously is a source of tension and discontinuity.

This last aim - recovery - results in the third major conundrum for CMHTs, the means by which people get better.

Professional passions and identities are at their greatest here, alongside a wealth of constructive debate and research.

There are numerous opinions on what recovery actually means and how it is best achieved, whether through medication, physical or social activity or - the most hotly contested area - psychological therapies.

Just as there is disagreement on the nature of mental disturbance, there seem to be irresolvable perspectives on the nature of psychological therapy itself.

Personal and professional opinions and abilities blur.

The mental health system faces challenges in determining how therapeutic expertise is achieved, gauged, recognised, how such professional expertise is distinguished from normal healthy relational functioning, and how the roles and functions of a professional therapist fit into ongoing CMHT work.

The upshot is that different teams may be dealing with different concepts in different ways, with different methods and aims. Certainty is sought to counteract the confusion.

Too often, impasses are resolved by resorting to defensive management of the greatest risk factors or by leaving strategic decisions to the profession with the most onerous responsibility and greatest power, namely psychiatry.

Looming over all these dilemmas is the fact that the daily functioning of a CMHT may not correspond with professional boundaries.

Inevitably this arouses anxieties, and two extremes threaten: the first is that professional boundaries will be dissolved, the second that they may be held ever more rigidly - valuing orthodoxy over efficacy.

Neither has to happen.

Ironically, the answer does not lie in trying to resolve these dilemmas conclusively, but in the way that mental health services are thought about.

CMHT work cannot be defined in terms of categorisations or specific results. Instead, teams work best when they have established solid and ongoing relationships and communications, whether these are with local referrers, communities and client groups or between team members.

Both the Department of Health's Guide on Community Mental Health Teams and the recent report New Roles for Psychiatrists recognise the importance of these factors.

But however CMHTs are prescribed, the functioning of any individual team is inevitably determined by the personalities of its members.

No matter what configuration of mental health services is decided upon, some catch-all facility will be required, implying a coming together of professionals with a differentiation of skills.

CMHTs are the ultimate testing ground for such a service and its values and philosophy, precisely because of their pivotal position, and the dilemmas and confusions they face.

Rather than being seen as the last resort, teams need to be the starting point from which more specialised provision can develop.

If we have courage, honesty and a commitment to open discussion, we can maintain our professional boundaries, yet we can also go beyond them to think creatively about what our clients really need.

The danger is that we retreat from the anxiety and complexity of the problem, and from our failure to know the solutions.

CMHTs break the mould, but people do not fit moulds. Teams are a metaphor, a microcosm, reflecting all our attitudes to mental illness. They offer the possibility of recognising that mental health is fundamentally about relationships.

Jim McCourt is a clinical psychologist at Birmingham and Solihull Mental Health trust.

For information on contributing to HSJ 's fortnightly mental health page, e-mail emma. forrest@emap. com