Community-Based Mental Health Care

Jean Pierre Wilken

Version July 2024

What is community mental health care?

Community mental health has different meanings. Historically, after World War II it was response to the closing of mental hospitals and transitioning of care to the community. Services in the community were created, such as outreaching ambulatory teams. In the 1980’s, psychosocial rehabilitation services were added to treatment services, including the development of supported housing, day care and day activity centres.

A main idea was that people should be able to receive services in their own environments, disrupting ordinary life as little as possible.

A broader conception of community mental health care developed since the 1990’s under the influence of notions of social inclusion, community participation and human rights (e.g. the U.N. Convention on the Rights of people with disabilities – CRPD). Services like vocational rehabilitation and supported employment were added to the spectrum.

Another stream in community mental health is to connect health care to other sectors,  combining population level approaches for prevention and promotion of health, using various resources in the broader network, both professional and informal resources, engaging social networks.

The last decennia, the recovery movement has also influenced community mental health care, putting the focus more on supporting personal recovery processes. In many countries peer experts have become part of the professional work force.

Six perspectives

A good resource about Community Based Mental Health Care is a paper that was published by EUCOMS in 2017 (Pieters et al., 2017). We use this paper to summarise important elements of  Community-Based Mental Health Care. The full paper can be found here.

The consensus document describes what good community mental health care looks like from six different perspectives, each constituting an important dimension for good community mental health:

  • Ethics
  • Public Health
  • Recovery
  • Effectiveness of interventions
  • Community network of care
  • Peer expertise

Ethics

  • The focus on human rights is a fundamental principle in community mental health care: the right of access to needs based care in the least restrictive environment and the right of full participation in community life. This includes civil rights, citizenship and cultural, spiritual, sexual and political freedom.
  • The right to mental health care for everybody who needs this has to be ensured in legal and policy documents.
  • Mental health services base their mission and vision on the United Nations’ Convention of the Rights of Persons with Disabilities (CRPD, 2008) that sets out the right to live, participate in the community, education, health, employment, housing and social protection.

Public Health

  • Community mental health services work for the health of all citizens in their catchment area. This includes existing clients, clients who need care but are hard to engage and potential future clients.
  • Addressing mental ill-health in the community means not only treatment and care but also prevention and promotion of good mental health. Taking actions to eliminate discrimination and reduce stigma are essential.
  • Community mental health care works with multidisciplinary teams in well-defined regions. The size of the region depends on the regional demography, prevalence of mental ill health and the resources of mental health care.
  • Mental health is a public health issue (relevant to high numbers of citizens in the population). It requires of mental health services to provide a recovery oriented approach and presence in the community.
  • Care for persons who are hard to engage is a core task of community mental health teams.

Recovery

  • Recovery is the client’s journey, and the task of mental health professional is to support and not to hinder this journey.
  • People can and do recover even from the most serious mental health problems
  • Community mental health teams focus on recovery of health, social functioning and personal identity.
  • Recovery-oriented care entails focusing on hope, strengths of the service user and leveraging the existing resources around the client, however big or small those resources may be.

Effectiveness

  • The task of community mental health services is to provide evidence informed context based mental health care.
  • Effective interventions are an important tool of community mental health services to support recovery of their clients.
  • Effectiveness of interventions is defined in addition to scientific evidence by: being well defined, reflecting client goals, durable outcomes, reasonable costs, adaptability to diverse communities and feasibility of implementation.
  • Evidence based medicine and the recovery attitude can be well combined.
  • Recommended interventions reducing symptoms are psychopharmacology, cognitive behavioural therapy and motivational interviewing.
  • Good community mental health care involves good somatic screening.
  • Recommended interventions to improve social functioning are individual placement and support (IPS) and Housing First.

Community

  • Community mental health care is a combination of input and supports from users, people from the user’s social network, and professionals when needed.
  • A community mental health service is a network within a broader network of self-help, family, friends and other informal resources and generic community services.
  • Community mental health requires interdisciplinary and intersectoral collaboration.
  • Primary care practices play a central role in the community mental health care model and provide care for people with a mental illness and their network.
  • There are several domains of integration in community mental health care: integration of medical and social interventions, integration of community and hospital teams and integration between different mental health service teams (e.g. dual diagnosis treatment).
  • Common elements of community mental health service delivery models include a

multidisciplinary team, ability to upscale or downscale care when needed, home-based care or care where the client needs it, focus on social and mental health care and a close collaboration with clinical mental health care in case of a needed admission.

  • The transition to community mental health care can be hindered by a financing system that favours institutional care (e.g. by rewarding bed occupation). The introduction of a prospective, programme- oriented financing system within the mental health care setting is recommend, favouring interdisciplinary and intersectoral collaboration.
  • The scope of community mental health is not restricted to severe mental illness (or psychosis) but includes all mental health needs – e.g. by being available for family doctors in the region.

Peer Expertise

  • Clients and service users are equal partners in the design, delivery, steering and evaluation of a service. ‘Nothing about us without us’.
  • At the individual level, shared decision making is a tool for co-creation of treatment planning.
  • Peer experts are an indispensable part of mental health teams.
  • Other professionals can use their own experience to build their relationship with clients and to provide well-tuned recovery support.
  • On a policy level service users are partners in the design and evaluation of services.

References

Pieters et al. (2017). Recovery for all in the community. Consensus paper on fundamental principles and key elements of community-based mental health care. EUCOMS. 

The European expert group on Transition from Institutional to Community-based Care. (2012). Common European Guidelines on the Transition from Institutional to Community-based care.

Thornicroft, G. (2011). Oxford textbook of community mental health. Oxford University Press.