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March 9, 2001

Bradford's Home Treatment Service uses five times less medication on its patients. It is also the first NHS service to employ a user who helps make clinical decisions. Adam James reports

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Throughout its history psychiatry has felt the collective wrath of dissatisfied patients.

Past and present user groups have argued that at best psychiatry is over reliant on medication and fails to address the social causes of distress. While at worst they argue the profession is damaging, and its powers of compulsory detention and treatment infringe on patients' civil liberties.

Yet such criticisms have failed to bring any fundamental changes to psychiatry-dominated mental health practice, particularly its allegiance to a medical model.

But Bradford's Home Treatment Service (HTS) has, over the last five years, pioneered a new philosophy which takes on board user concerns. It is the first UK mental health NHS service to invest a user, Peter Relton, with powers to decide how clients are treated.

Whereas mental health services increasingly employ users as general "user-development" workers Relton is the first to be attached to a specific clinical team. In so doing Bradford's HTS, an initiative supported by local user groups, has demonstrated how the buzz words of user/professional partnership can be turned into working reality.

A user for the last 35 years, Relton sits alongside the team's two psychiatrists, eight nurses and three social workers at the three weekly review meetings when clients are discussed. He has equal say on all matters - whether it be the progress of a client, how to spend the service's budget, or team development.

"My position means I can make a direct impact on professionals' attitudes and the team's philosophy," explains Relton, who also serves on Bradford MIND's management committee. Most power in mental health services lies in the hands of the psychiatrists. But here in Bradford psychiatrists have made the remarkable step of giving some of their power away to users."

Relton's appointment won the seal of approval from the trust because of the reputation of Bradford HTS team leader consultant psychiatrist Dr Pat Bracken who used to work with North Birmingham Trust's innovative home treatment service.

Describing himself as a "critical psychiatrist" Dr Bracken works with a social model of mental illness rather than the orthodox medical one. He believes mental health problems have their roots in experience rather than biology. Dr Bracken says Relton has brought benefits to his team which all psychiatric services could learn from.

"As a user Peter knows what is like to be talked and discussed about by professionals. He has helped shape the team's culture away from a feeling of them, the patients, and us, the professionals. He can also communicate with patients in a way the rest of us can not."

The team, which takes referrals directly from GPs, only treats patients in their own home believing it to be a more appropriate environment to recover from distress as opposed to the turbulent and often impersonal psychiatric ward. And with Relton's input the team has made a further radical diversion from the medical model by not using psychiatric diagnoses. Rather than diagnosing a client with schizophrenia or manic depression, team members will instead focus on a client's needs and events in their life.

"From the patient's point of view there is nothing to be gained by giving he or she a diagnosis - particularly schizophrenia which is such a stigmatising label," says Dr Bracken. "We prefer to say, for example, that people are having strange experiences or are hearing voices."

For example, one woman was referred to the team with a diagnosis of schizophrenia and had "delusions" of being attacked. But when the team's workers visited her at home they discovered her husband was regularly beating her up. It was this violent domestic environment which was the mort pressing problem in the woman's life.

"Yet up to this point other services had taken her husband's version of events that his wife was mad," says Relton who coordinates training for the team. "Bizarre behaviour can always be made meaningful if attention is paid to what is going on in an individual's life."

One consequence of Bradford HTS's rejection of the medical model is that it relies less on medication. Instead it prefers non-physical treatment methods devised by user groups themselves.

For example, a client experiencing problems with voices will be asked to discuss the voices' content and will be supported in devising ways of coping with them - strategies promoted by The Hearing Voices Network In this way five times less psychiatric medication is used on Bradford HTS clients than hospital patients.

"We only use medication as a short term effect to relieve anxiety, and in lower doses," says Dr Bracken.

Dr Bracken believes Relton's appointment plus the team's commitment to treat clients at home represents what it means to practice according to a fundamentally alternative mental health philosophy.

"We are showing that you really can do mental health work without using psychiatry and psychiatric concepts," he proclaims. "Critics have said our different philosophy could not work in real life. Well we work in the inner city, not the leafy suburbs of London - and this is as real as it gets. We have received very positive reactions. Not just from user organisations but a growing number of doctors who find traditional psychiatric failing to meet their patients' needs."

The Department of Health has also recognised Bradford HTS's achievements and awarded it a Beacon Status for good practice. With this accolade came an extra £25,000 to promote its work to other mental health services around the country.

"This represents the importance of what we are doing here, and if the mental health service wants to gain more credit from users it has to give us more say in how things are run" says Relton.

(C) Copyright Psychminded Ltd, March 2001.