The need for a rights-based approach to acute models of care
Johnson et al1 provide a comprehensive overview of the range of acute services and models of care currently considered and utilized by mental health systems, primarily in high-income countries. Their paper represents an excellent starting point for the evaluation of the range, access and quality of support available to those who experience acute psychosocial distress2. The authors make clear that there are multiple possible pathways into care, numerous modalities of assessment that can be applied, and an equally diverse set of potential options for support following assessment.
The breadth and depth of all this is nothing short of remarkable. What is equally remarkable, however, is the lack of a clear evidence-based direction provided by research. This is contrary to the widespread belief that an evidence base exists underpinning the predominantly biomedical approaches found in most high-income countries. As Johnson et al point out, most studies are negative in their findings or do not find benefit for the care model proposed. This results in making approaches to the planning, implementation and evaluation of acute care a wicked problem3. The “scope” and “status” of acute services currently generates a very real conundrum for service planners and individual clinicians: what are the best approaches to improving access and quality of care?
Actually, it is unlikely that there will be “best approaches” that are generalizable to individuals in terms of their presentation, time, culture or health care model. What is required is a contextually relevant model of care with adequate evidence. We would suggest that judgements as to whether the acute care approaches available in a society are sufficient and appropriate mostly belong to the patients that receive them and their support networks4. In order to make this evaluation, it seems likely that an understanding of acute psychosocial distress from the patient perspective is a prerequisite and that this should include an understanding of patient rights.
Taken as a whole, the existing evidence suggests that biomedical models for assessment (such as assessment in the emergency department) are largely unhelpful from a patient perspective and may increase the likelihood of inpatient care. This care is often implemented on the basis of a poorly specified “risk” that many wards are not designed to mitigate. Alternatives are therefore needed to develop more effective acute assessment and care.
It is interesting to see that home crisis teams, that are not based in a theoretical model, are more positively received by patients, as are residential community crisis homes. These exist throughout New Zealand and anecdotally reflect the positive experiences reported in the literature. Both of these models are less clinical in orientation, with a focus on the needs of the person in distress and approaches to meet them, as opposed to a focus on risk. The implication is that the biomedical models outlined as the “tip of the spear” may be insufficient or even outdated, and that co-produced acute care models are needed to adequately supplement them in meeting the needs of patients and their support networks.
We note the differentiation between the overview pertaining to high-income countries and that regarding low- and middle-income countries (LMICs) in Johnson et al’s paper. What is somewhat of concern is the critical lens applied to the issues and approaches that exist in those LMICs. The identified systematic review of mental health interventions for crises in non-specialist settings in LMICs5, which found a lack of evidence-based guidelines for crisis care, is consistent with the findings of Johnson et al’s overview generally. As the United Nations (UN) Special Rapporteur pointed out in 2020, “globally, almost all contexts share the need for a paradigm shift in mental health, although what that shift looks like in practice is a matter of much debate… while a dominant global status quo in mental health exists, it is fracturing under the pressure of these divergent and powerful movements and experiences”6. Similarly, the World Health Organization (WHO) reports that “sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries”7. The issues identified in LMICs extend, we would suggest, their reach also into high-income countries.
One of the powerful movements to which the UN Special Rapporteur refers is represented by the expectations of countries that have signed and ratified the 2006 UN Convention on the Rights of Persons with Disabilities. This includes particularly the right of persons with experience of disability (including psychosocial disability) to legal capacity, which encompasses both legal standing (the ability to hold rights) and legal agency (the ability to exercise those rights).
A common assumption to counter this approach is the perceived need to substitute the choices of a person with acute psychosocial distress in order to meet his/her needs, for example by using mental health legislation. Arguably these concerns rest on poorly defined concepts, such as “insight”, and there is increasing debate around appropriate capacity assessments8, even in acute circumstances9. In response, the Convention requires that people are provided with support to make decisions in accord with their own will and preferences even in situations where they may have impaired decision-making skills.
As identified by Johnson et al, the recently published WHO guidance7 sets out the core principles of rights-based, recovery-oriented approaches to community mental health services, including crisis services, as being a commitment to respect for legal capacity, non-coercive practices, community inclusion, participation, and the recovery approach. Fundamentally, the needs and rights of the person in distress should be the guide to the model of care delivered.
In sum, Johnson et al provide an excellent overview of the current range of services and quality considerations involved in acute psychiatric care. They point out that the literature is fractured or does not support many of the day-to-day interventions offered. The changing global context, with an ever increasing recognition of the rights of people experiencing acute psychosocial distress, also challenges the status quo.
We would echo the authors’ conclusion that new approaches need to be developed, evaluated and implemented, and we would suggest that rights-based, recovery-oriented approaches should inform any increase in the range, and improved access and quality of, acute psychiatric care. Co-production with people with lived experience and their support networks is likely to best facilitate this change.
