Service providers throughout Europe have come together to define a shared vision for high quality community mental health care. This endeavor centers a human rights perspective and peer expertise to promote recovery for all.
The European Community Mental Health Services Providers (EUCOMS) Network recently published a position paper that outlines six principles to improve structures within community mental health and inform governments, commissioners, and funders.
“In line with the vision of EUCOMS members good mental health services are described as comprehensive, equally accessible, integrated, recovery oriented, aimed to protect and respect human rights, employ effective and tailored interventions, and work in collaboration with service users and his/her network.”
In 2015, the EUCOMS network was established when providers gathered for a meeting on integrated care and assertive outreach. In recognizing trends of deinstitutionalization and the growing need for quality community-based care, they sought to envision and redefine “good” community mental health care.
The development of community mental health services has been a major health policy goal as provider and service-user attitudes have shifted away from long-stay psychiatric hospital settings. However, hospitals continue to receive the lion’s share of funding and resources, rendering community care lower on the list of political priorities. In addition to this, there is a lack of consensus among stakeholders regarding how to successfully develop community-based care. Barriers include the lack of cooperation between health and social sectors, resistance to change, lack of clear, strong leadership, and difficulties surrounding integration of mental health into primary health settings.
Based on the need to identify the principles and key elements of high-quality community-based care, the EUCOMS network consulted with mental health and peer experts and researchers to develop a position paper. This paper, authored by René Keet and the EUCOMS team, was recently published in BMC Psychiatry. The paper’s objective is to contribute to narrowing the gap between evidence, policy, and practice:
“EUCOMS aims to contribute to the discussion on how to narrow the gap between evidence, policy and practice in Europe supporting the regional implementation of quality community mental health care taking into account the diverse contexts.”
Six principles were identified by the EUCOMS network as the principle components to inform organizing and structuring community-based care. High quality community mental health care: “(1) protects human rights, (2) has a public health focus, (3) supports service users in their recovery journey, (4) makes use of effective interventions based on evidence and client goals, (5) promotes a wide network of support in the community, and (6) makes use of peer expertise in service design and delivery.”
Human rights are featured as a foundational principle. Indeed, Keet and colleagues note that the movement to emphasize human rights was a driving force to shut down psychiatric hospitals and move toward community-based care. The EUCOMS network aligns with the UN’s Convention on the Rights of Persons with Disabilities (CRPD) and Special Rapporteur Dainius Pūras (see MIA report) to structurally improve mental health facilities in accordance with a human rights framework.
“The position paper recommends preventing exclusion from community life which negatively impacts the ability to integrate in society, achieve recovery goals, and lead a meaningful life. To realize this, governments need to ensure that the rights of all people are respected on the same legal basis. This requires a revision of national policies and legislative frameworks.”
The authors clarify that public health refers to equity between groups, as well as population-level health. This goes beyond treatment and includes promotion and prevention. In this way, a public health perspective is fundamental to community-based care and extends the human right to “the highest attainable standard of health.” The paper describes numerous considerations to facilitate the successful implementation of public health goals at the community level.
Throughout the position paper, the EUCOMS network consistently emphasizes a need for providers to support service users on their journey to recovery by offering hope, collaborating rather than making decisions for the service user, and re-centering the focus on service-user strengths. Recovery is described as complex, both individually-defined and multidimensional.
The authors write, “Recovery has several dimensions, including clinical recovery (relief of psychiatric symptoms); functional recovery (meaningful participation in society) and personal recovery (restoring personal identity). Recovery is a unique individual process or experience that may best be described as a journey. In good community-based mental health care, professionals are companions on this journey for as short a time as possible but as long as necessary.”
Underpinning successful recovery and community-based mental health care overall is the use of scientific evidence to guide interventions, according to EUCOMS. They recommend the use of “evidence-based psychological treatment.” Medication ought to be used “as a tool and not as an aim,” they clarify. The EUCOMS network attempts to merge the disparate camps of evidence-based and recovery-oriented care, noting that the two must inform one another. They write:
“The third and upcoming era in mental health is the moral era, with a reduction of mandatory measurements, giving up the professional prerogative, and a transition to civility and collaboration with patients and carers. The move towards the third era is driven by limited evidence of improved outcomes of biological and psychological approaches alone in mental healthcare, and the growing knowledge on the powerful influence of social factors, like inequality in mental health.”
At the core of community mental health care is the recognition that mental health involves a whole systems approach that draws from the expertise of collaborating providers on a multi-disciplinary team. To increase the resilience of service-users and their surrounding networks, it is important to consider their relational support networks and to bridge the gap between professionals and nonprofessionals, the EUCOMS network maintains.
“The professional expertise of team members is combined with the lived experience of users. The same principle can be applied for intersectoral collaboration,” they write.
However, these aims may be obstructed when economies of influence dictate mental health systems and interventions. According to the authors,
“The integration of the community mental health care services, sectors and collaboration with the social network of the service user can be hindered by a financing system that favours institutional care (e.g. by rewarding bed occupation). Therefore, it is recommended to create a flexible financing system that allows incentives for different services that address the relevant life domains of people with a mental illness.”
In addition to scientific evidence and the expertise of providers, the EUCOMS network suggests valuing the expertise and contributions of peers in community mental health settings. Peers not only provide a living example of the possibility of recovery, they can also provide invaluable guidance and support to others on their journey to recovery by their involvement in designing, implementing, and evaluating interventions. In the spirit of “nothing about us without us,” the EUCOMS network suggests redistributing power to engage service users as peer experts and providing the appropriate resources to facilitate this practice.
Importantly, despite attempting to draw from the perspectives of diverse stakeholders, the EUCOMS team did not have equal representation across stakeholder groups. The authors disclosed the overrepresentation of members from Western European countries and that they received relatively little input from service users and carers.
“With this position paper EUCOMS hopes to contribute to the discussion on how to improve structures in mental healthcare, and to narrow the gap between evidence, policy and practice in Europe. Essential next steps for EUCOMS to succeed are to connect and involve the diverse stakeholder groups in ongoing dialogue, research consensus and capacity building, and advocacy.”
Keet, R., de Vetten-Mc Mahon, M., Shields-Zeeman, L., Ruud, T., van Weeghel, J., Bahler, M., . . . Nas, C. (2019). Recovery for all in the community; position paper on principles and key elements of community-based mental health care. BMC psychiatry, 19(1), 174. https://doi.org/10.1186/s12888-019-2162-z (Link)