The psychotherapy department and the community mental health team : bridges and boundaries

Aimsand method The aim of the studywas to clarify the role of psychotherapy departments in relation to a general psychiatric service, and in particular community mental health teams (CMHTs). Literature reviews of therapeutic activities in CMHTs and of psychotherapy delivery methods were undertaken. The implications of the National Health Service Executive document on Psychotherapy Services in England was considered, based on experience of the psychotherapy-general psychiatry interfaces in North Devon and Bristol. Results Psychological therapiesare an integralpart of psychiatric treatment provided in CMHTs.but are often delivered without careful assessment, training or supervision. Psychotherapy departments contain expertise in the range of psychological therapies, but are sometimes perceived as remote from everyday psychiatric practice. Ways in which the divide between general psychiatry and psychotherapy might be bridged are suggested. A multi-disciplinary psychological treatment unit can offer specialist resources for the assessment and treatment of complex cases, especially those with personality disorders; psychological interventions in psychosis;and brief focused therapies for neurotic disorders unresponsive to drugs. Clinical implications Consultationand liaisonwith the CMHTshould become a key element in the work of a psychological treatment unit, and structured therapies under supervisionsimilarlycentral to the work of CMHTs.


Services in England Report
A Government-commissioned survey of NHS psychotherapy services in England (National Health Service Executive, 1996) showed that the bulk of psychotherapeutic work is not carried out by qualified psychotherapists and does not take place in psychotherapy departments.It is delivered by general mental health professionals in a variety of settings: for example, counsellors working in general practice or community psychiatric nurses (CPNs) based in community mental health teams (CMHTs).The report pro poses a classification of psychotherapies which takes account of this.Type A' psychotherapy is that most likely to be found within CMHTs as part of a general package of care of which psychotherapy is but one component.Type B and C therapies are more specialised eclectic or model-based therapies, typically delivered, re spectively, within psychology or psychotherapy departments.
The report is critical of the organisation, quality control and efficacy of much of what currently passes for psychotherapy.It proposes a central role for psychotherapy departments or psychological treatment units (PTUs) in improv ing the coordination and delivery of safe, effective, equitable and accountable psychother apy.It argues that psychotherapy should, through training and supervision, become pail of mainstream psychiatric treatment, and en courages PTUs to become multi-modal rather than exclusively psychoanalytic.

Community mental health team
In many mental health units, general psychiatric work is centred on the CMHT.Such units frequently operate a 'single point of entry' system in which referrals are scrutinised by a coordi nator and then allocated as appropriate to team members, CPN, psychologist, occupational therapist or psychiatrist, for assessment.The result of that assessment is then fed back to a multi-disciplinary team, and following Govern ment guidelines (National Health Service Execu tive, 1994) each case is then prioritised (according to the Care Programme Approach (CPA) 'level') and allocated to a keyworker, who supposedly coordinates the various services and treatments required.
In practice, this system can be problematic in two main ways, the first is the sheer bulk of referrals which the team may receive.This can lead to enormously heavy case loads for CMHT workers, who can do no more than offer minimal support to many of their clients.Second, there is often lack of clarity about the nature of the psychotherapeutic input required by particular clients.The CMHT assessment is not informed by specific psychotherapy assessment skills, and patients may either inappropriately be offered Types B or C treatments by untrained therapists, when a less intensive supportive approach is indicated; or conversely may offer vague 'sup port' for want of relevant training or targeted psychotherapy services.

Psychological treatment unit
Specialist psychotherapy services are unevenly distributed across the country.Some districts have no consultant psychotherapist, despite a Royal College of Psychiatrists' recommendation, first endorsed 20 years ago, that there should be a minimum of one consultant psychotherapist per 200 000 of the population (Royal College of Psychiatrists, 1991).District psychology services are generally better established, providing psy chotherapeutic input into mental health units, liaison psychotherapy services to medical and surgical departments, and sometimes sessional work in general practitioners' surgeries.How ever, waiting times for treatment are often very long, and treatment is not necessarily directed towards those with severe mental illness.
Relationships between psychology and psy chotherapy services vary from the distant, through cordial cooperation, to rare instances of complete integration into a psychological treatment unit.Psychotherapy departments have tended to be predominantly psychoanalytic in orientation, while psychology departments are more likely to specialise in cognitive-behavioural (CBT) treatments.Referrals to both come directly from general practitioners, and internally from the CMHTs.
Relationships with CMHTs vary.Psychologists may be members of the team, usually on a parttime basis.Psychotherapy departments have traditionally had no direct links with the CMHTs, but there is an increasing trend for members of the PTU to devote sessional time to the CMHT, offering assessment of difficult cases and super vision for team members.Sometimes the CMHTpsychotherapy relationship is centripetal, with CMHT workers seconded to the psychotherapy department for one or two sessions per week.
Following an intensive assessment interview, often backed up with self-report questionnaires, psychotherapy departments generally decide whether referred patients are 'suitable' or not for psychotherapy, allocate them to a waiting list, from which they are taken on in due course, frequently by a junior therapist under the super vision of a senior member of the team.As with CMHTs, appraisal of 'suitability' is limited by the therapy options available.If analytic therapy is the predominant model, then the criteria for analytic therapy will determine the outcome of assessment, if it is counselling and short-term groups, then counselling and short-term groups is what clients will be offered, and so on.
Recently some departments have attempted to move away from the rather narrow focus thus far described.The psychology-psychotherapy rap prochement characteristic of PTUs has the advantage of combining psychoanalytic, CBT and sometimes systemic skills, thereby offering patients a greater range of psychotherapeutic options, and broadening the usefulness of the PTU to the mental health unit as a whole.A step further moves psychotherapy away from modelbased treatment towards targeting specific dis orders.For instance, a PTU may offer a person ality-disorder service, sometimes combined with a psychotherapy day hospital (Bateman, 1997).Psychotherapy may be offered to those suffering from early trauma (usually sexual abuse), or as a central strand in services for those with eating disorders, resistant depression, recurrent delib erate self-harm, first episodes of psychosis or sexual disorders.Here the modality of therapy is tailored to the needs of the patient and the illness, and can more easily form part of an evidence-based pattern of treatment (Roth & Fonagy, 1996).

New patterns of service: the interdependence of the PTU and the CMHT
How can these two areas of mental health work -that of the CMHT and the PTU -the one containing enthusiastic but uncoordinated po tential, the other a repository of expertise but often sequestered from the hurlyburly of general psychiatry, be brought more creatively together?How can proven effectiveness be translated into clinical efficacy?An earlier paper advocated a 'hub and spokes' arrangement in which a multidisciplinary, multi-modal PTU retained a critical central mass of psychotherapeutic expertise, while reaching out to the rest of the mental health unit (Holmes & Mitchison, 1995).This paper builds on that model, but suggests how it can be interlocked with a more structured pattern of psychotherapeutic work within the CMHT.
The National Health Service Executive (1996) document emphasises the need for services to evolve in response to local needs, skills and enthusiasms.
Nevertheless current trends sug gest a number of guiding principles which can inform the relationship between CMHTs, PTUs, and primary care.

ThePTU
The prime role of the PTU is to be a repository of psychotherapeutic expertise offering training, supervision, assessment and treatment of com plex cases to the CMHTs.The PTU is explicitly multi-disciplinary and divides its work along two dimensions.The first is the traditional modelbased one, and enables members to offer training, supervision, and treatment in the various modalities (e.g.family therapy, CBT, psychoanalytic).
At the same time, expertise in diagnosis-based therapies needs to be developed.Here too local needs and expertise will determine patterns of service, but, as a minimum, three main areas of expertise need to be developed: (a) psychological interventions in psychosis, as part of an early intervention in psychosis programme: (b) specific treatments for complex cases of anxiety/depres sion, usually with time-limited therapies: (c) a service for patients with personality disorder, with especial emphasis on selection of cases suitable for intensive longer-term therapy.Other possible foci might include eating disorders and somatisation disorders.
Each division is headed by a senior member of the PTU.There will be a tendency for CBT and systemic therapists to be drawn to the psychosis and anxiety/depression teams, while analytic therapists may focus more on the longer-term treatment of patients with personality disorder, but no single approach is exclusively effective, and integrative treatments need to evolve (Albeniz & Holmes, 1995).Members of the PTU will be organised in a number of sub-units, each of which with its own identity, but which meet regularly together for audit, case discussion and other academic work.

The CMHT
In numerical terms the majority of psychother apeutic work within a mental health unit will be carried out in the CMHTs.There is an urgent need for improved organisation, audit and enhancement of psychotherapeutic skills within the CMHT.
After assessment, cases referred to the CMHT are assigned to a number of categories: (a) refer back to primary care, no further intervention needed; (b) refer to early intervention in psycho sis team; (c) refer to brief intervention team for focused work for mild/moderate depression or anxiety (e.g.anxiety management or self-esteem group, CBT, focal dynamic counselling/therapy); (d) refer to long-term therapy team for patients with personality disorder, and/or early trauma; (e) intensive psychotherapeutic intervention not required, assign to supportive therapy at low intensity.
As with the PTU, each member of the CMHT has a dual role.Members divide their work between assessment and carrying a long-term case load as at present, but are also part of a specific psychotherapeutic team.The latter would have a coordinator (who might be a member of the CMHT or a visiting member of the PTU) with its own waiting list.Each member of the team would have defined number of treatment 'slots', thereby limiting the mental health worker's case load.All cases would be supervised, audited and members would parti cipate in skills acquisition, reading seminars, case presentation etc.

Care pathways in psychotherapy
The progress of each referral can be tracked along a number of possible routes, or 'care pathways'.
Patients suffering from mild depression re ferred by their general practitioner, will, after assessment, be allocated to the brief interven tion division within the CMHT.After waiting until a 'slot' arises they could be offered a timelimited self-esteem group run along CBT lines by two members of the CMHT team, supervised by the visiting CBT therapist from the PTU.Those whose symptoms have remitted to some extent, but who continue to have major inter personal difficulties making them vulnerable to further episodes of depression, will at this point be referred on to the PTU, where, following assessment, they may be allocated to longerterm treatment, perhaps in a group run along group analytic lines, managed by a qualified therapist.
More complex cases, say of severe personality disorder, would after initial screening by the CMHT, be referred directly to the personality disorder service which is part of the PTU, and be offered longer-term treatment from the start of their contact with secondary services.
Patients suffering from a first episode of psychosis, perhaps following a period as an inpatient, will be taken into the CMHT and held supportively there until a 'slot' arises in the psychosis intervention programme.They would then be offered intensive CBT and family therapy, under the supervision and auspices of a member of the psychosis intervention team from the PTU, although the therapists will be members of the CMHT.At the completion of Psychotherapy departments and MHTs treatment (perhaps after 6-9 months) the patient will be allocated to routine supportive holding under CPA with a keyworker within the CMHT.

Conclusion: management and brokerage
The purpose of this paper has been to describe ways in which psychotherapeutic treatments can become part of routine psychiatric care.The evidence for the efficacy of such treatment exists (Roth & Fonagy, 1996), and there is a growing body of knowledge about the economic as well as clinical advantages of combining pharmaco logical and psychological therapies (Gabbard et al, 1997).It still remains to convert research evidence and clinical enthusiasm into everyday practice.Given the strength of its evidencebase it is scandalous if psychotherapy is to remain a luxury to which patients only have access if they happen to live in a favoured area, or can afford private treatment (Holmes & Lindley, 1998).
The key to developing such services lies in the relationship between the PTU and CMHT.Shaping this relationship is a delicate manage ment task, involving as it does the sensitivities and professional identities of general psychi atrists, psychologists, medical psychotherapists and psychiatric nurses.The necessary 'broker age' between them is likely to come initially from within the PTU, and will stand or fall depending on the relationship between the consultant psychotherapist and his general psychiatric colleagues (Working paper from the Psychother apy Faculty of the College: The development of psychotherapy services: the role of the consul tant psychotherapist'; further details available from the author upon request).Medically quali fied consultant psychotherapists combine psy chotherapeutic and psychiatric expertise, and should be accepted culture-carriers in both fields.
Mental health units and commissioning bodies wishing to provide equitable, evidence-based mental health services that are effective and acceptable to the public would do well to encourage such brokerage.Creating and sup porting consultant psychotherapist posts is an essential part of that process.