An Ethnography of Psychiatric Home Treatment

Cameron Murdoch Spence

Thesis submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy
July 2019

Department of Global Health and Social Medicine

King’s College London

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Abstract

This thesis is an ethnography of a South London psychiatric home treatment team (also called
a crisis resolution and home treatment team) practicing within the context of government
“austerity” policies that followed from the 2008 financial crisis. It draws on 15 months of
ethnographic fieldwork, 40 interviews with service users and staff, over 200 home visits, and
observations from many other formal and informal settings. Following an account of the
history of home treatment teams and their entanglement with austerity, I explore the way in
which the Home Treatment Team is being used by a mental health trust to manage mental
health in conditions of austerity, which have increased the numbers of people seeking mental
health treatment as well as pressure on in-patient beds, and reframed home treatment as a
financially attractive alternative to hospitalisation. This has led to a restructuring of the work
of the Home Treatment Team to contain increasing numbers of distressed individuals within a
flexible framework. I show how this restructuring impacts particularly on those service users
considered “difficult” and those who are not white. I examine the clashes between the
“timescapes” of service users’ rhythms of life and the institutional timescapes required by
home treatment. I place the work of Home Treatment Teams in the wider environment in
which the Team operates, analysing this as a landscape of distress. This landscape includes the
effects on mental health of the changes in welfare regimes, housing regeneration, and
precarious living conditions as well as precarious work. In conclusion, I bring these different
dimensions of Home Treatment together to show how home treatment teams have been
reshaped in order to manage austerity, but also how the work of those teams can be a source
of relief from the landscapes of distress that have been exacerbated by austerity.

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Contents

Acknowledgements ............................................................................................... 4

List of Figures .................................................................................................... 5

List of Acronyms and Abbreviations.......................................................................... 6

Chapter 1: Introduction .................................................................................... 7

Chapter 2: Methods ....................................................................................... 34

Chapter 3: A History of Home Treatment: A History of Austerity? ................... 58

Chapter 4: Home Treatment Practice ............................................................. 84

Chapter 5: Anatomy of a Home Visit: Part 1 ...................................................109

Chapter 6: Anatomy of a Home Visit: Part 2 ................................................... 131

Chapter 7: Managing a Political Economy of Care ........................................... 152

Chapter 8: Time, Space, and Resource Scarcity in Service User Experiences ... 180

Chapter 9: A Landscape of Distress: Austerity in the Community ................... 208

Chapter 10: Conclusion ................................................................................ 242

Appendix ....................................................................................................... 271

References ......................................................................................................303

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Acknowledgements

The following work is dedicated to my participants: without the caring, patient, and accepting
staff of the Home Treatment Team and the service users who opened their homes and lives to
me, there would be no dissertation. I hope that I have adequately and honestly portrayed the
difficult reality of your lives.

This dissertation would not have been possible without the amazing support of my life partner
Amber. She means the world to me and worked tirelessly through my PhD making all of this
possible. I turn now to the work of returning the favour for her PhD.

Our parents and family members have also supported us through this endeavor. Thank you to
the Boatright’s, Mahoney’s, Spence’s, Beck’s, and MacLean’s. You have all been so kind and
supportive in so many ways. Thank you also to James Chim and John Eaton for supporting
this endeavour and believing in me.

Thank you to Hanna and Nikolas for never giving up on me or my complicated journey
through this PhD. I worked on this dissertation surrounded by some of the most brilliant and
thoughtful colleagues I’ve met. Tara, Guntars, Sebastián, Val, Giulia, Penny, Sebastian F, and
James thank you for your encouragement, words of wisdom, and gentle critique. I hope
someday to find a set of colleagues as wonderful as you.

For Amber, Eli, Jean, Rose, and Jenny

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List of Figures

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List of Acronyms and Abbreviations
A&E Accident and Emergency Ward in a Hospital
A&R Assessment & Referrals
AMHP Approved Mental Health Professional
ARC Acute Referral Centre
BME Black and Minority Ethnic
BPD Borderline Personality Disorder
CAT Cognitive Analytic Therapy
CMHT Community Mental Health Team
CPoS Central Place of Safety
CQC Care Quality Commission
CSL Clinical Service Lead
CYPS Child and Youth Protective Services
DBT Dynamic Behavioural Therapy
GP General Practitioner
HTT Home Treatment Team
MHA Mental Health Act
NHS National Health Service
NSF National Service Framework
PbR Pay by Results
PICU Psychiatric Intensive Care Unit
PIG Policy Implementation Guide
PLN Psychiatric Liaison Nurse
PLS Psychiatric Liaison Service
PRN Pro re nata (as and when needed)
PTSD Post Traumatic Stress Disorder
SLaM South London and Maudsley Trust
TCL Training in Community Living
WCA Work Capability Assessment
WRAG Work Related Activities Group
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Chapter 1: Introduction

Over the course of several home visits I got to know Ninette, a former ballet dancer who had
struggled with hearing voices for quite some time. She had lived in a hostel before residing in
her current flat. One night at the hostel, she was hanging around with the other residents in
the kitchen, chatting, when another woman thought Ninette was flirting with her boyfriend.
The woman grabbed Ninette by the hair and slammed her head on the counter, knocking out
her two front teeth. The attack sent Ninette into a tailspin, landing her in an acute psychiatric
inpatient unit under a legal section. Consequently, she lost her spot in the hostel and was
made homeless while she was on the ward. Instead of enabling her to press charges, the ward
staff concentrated on finding her a more permanent home and liaised with the mobile dentistry
unit to replace her teeth. When I met her, she had settled into a new flat in a nicer area at the
other end of the borough.

Nathan, a nurse with the home treatment team, and I arrived at her door after walking up two
flights of stairs in an art-deco-style apartment building. We knocked on her door and
introduced ourselves. Ninette let us in and we followed her as she walked down the hallway,
stepping over a pile of mail on the floor. In the living room we sat on a futon and Ninette
kneeled on a rainbow-coloured mat on the floor across from us. The medication Nathan was
to dispense on this visit was very effective at bringing psychotic episodes under control
quickly and was working well for her. Unfortunately, the medication also caused rapid weight
gain, leaving her slightly overweight. When asked about her weight, she changed the subject
as she was still coming to terms with its relation to the medication she found helpful.

Instead, Ninette spoke to us about the voices she heard, which continued to bother her but
were steadily reducing in volume. Their presence still left her nervous enough that it was hard
for her to shop for groceries from the small store down the street. She would enter the store,
quickly become overwhelmed and anxious, and rush back to the safety of her home. Nathan
suggested trying again with a team member for support that afternoon. She also mentioned

7
that she had received a letter confirming her address that she thought was suspicious. We
suspected it was a letter from a creditor, but Ninette thought it might mean her phone was
being tapped. She was clearly continuing to suffer from some residual paranoia, but it was
difficult to tell how much.

As we spoke, I took in the room around me. There were healthy plants on the windowsill,
indicating that she had friends who watered them while she was away in the ward. She had a
full-size, stand-up mirror with a pair of well used ballet shoes hanging on the corner. As I
looked at the mirror, I thought about how those shoes reflected her past. It brought to mind an
image of Ninette looking into the mirror and seeing the shoes, a constant reminder of her
inability to shake the weight that she put on from the pills. Perhaps Ninette’s relationship with
the shoes was a cruel optimism, and her desire to dance again actually an obstacle to her own
flourishing (Berlant, 2011). A constant reminder of the past, her body reflecting the future—
continued use of the medication would cause her to gain more weight but would also help to
lessen the voices and paranoid thoughts. The past was felt in the present and elements of the
present cast into the future.

Home treatment teams (HTTs) have a mirrored effect to them as well; their past is reflected
in the present. These teams were created during the great depression—a time when austerity
programmes failed to produce promised economic growth—as a way to reduce overcrowding
in wards and limit financial expenditure (Blyth, 2013; Lemkau & Crocetti, 1961; Schui, 2014).
When I conducted my fieldwork in 2015 and 2016, these teams had returned once again to an
environment of austerity. At the time I began my field work, little was known about how
exactly HTTs were being used, what their practice was, or how they and their service users
were being affected by contemporary austerity policies (Gilburt, 2015; Gilburt et al., 2014).
The practice of these teams had not been extensively studied, nor had it been specifically
mandated by the government which resulted in great flexibility in the way HTTs practise
(Johnson & Bindman, 2008). Today, with the increased pressure on mental health trusts to
balance their books and the assumption of further cuts, HTTs are becoming an integral part of
service redesign (Gilburt, 2015; Gilburt et al., 2014). The question of just what these teams do

8
and how are they being used is significant for the teams themselves, but even more so for the
experience of service users of these teams, who are also dealing with deteriorating living
conditions as a result of successive austerity policies.

In my ethnographic fieldwork, I focused on one HTT, its practice and the people who used
their service. I sought to answer the question of what happened to the practice of an HTT
and the lives of its service users when austerity and a drive for financial solvency became the
central activity of a mental health trust. To do this, I tracked the changing practice of the
team, the lives of its service users, and the environments in which they worked, lived, and
existed, over a span of 15 months (2015-2016) in the London Borough of Lambeth, UK. As I
moved in and out of the homes and communities of service users, it was critical to capture the
currents of austerity that ran through the landscape of the UK welfare state, currents that
were changing the topography of Lambeth and producing waves that would crash over and
over onto the lives of service users, increasingly driving mental health crises.

Placing the work of the HTT in the wider environment in which the team operated allowed
me to analyse and construct a landscape of distress. This landscape included the ways that
changes in welfare regimes, housing regeneration, precarious living conditions, and precarious
work had an effect on mental health. The team worked within these currents of austerity,
dealing with the effects of a landscape of distress, while at the same time being realigned by
the Trust and performance-managed towards discrete financial goals. I will show that this
concentration of the HTT on the Trusts financial goals became detrimental to those who
were, and who continue to be on the margins of mental health service user populations. I also
examined the experiences of these service users and others within the context of a system
under financial pressure, utilising the dimension of time to highlight the clashes between
institution and person. This helped me to answer the question of how these teams could
simultaneously help to manage austerity within the Trust, while also being a source of relief
from a landscape of distress for some, and just another stop on an institutional circuit for
others.

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The first step in presenting my ethnography is to introduce a number of concepts and other
aspects of my analysis that provide a frame and foundation for this dissertation. To begin, I
will explain what an HTT is, as they have been referred to by many different names and are
the least well-known mental health service in the UK. I will then present the reader with a
short analysis of why the government chose home treatment, what this says about the way it is
being used, and how this helped to direct my ethnography and analysis. Following this, I will
begin to introduce some of the fundamental concepts within my research, starting with a
definition of what austerity means in this work. I then will introduce how I will deal with time
as a dimension of my work and, as a result of using time, I also will explain where acceleration
and speed fit into the work of the HTT. Finally, I will provide an overview of Lambeth as a
distressing landscape and finish this chapter with a preview of how each subsequent chapter
will present my ethnography.

What is a Home Treatment Team?

A home treatment team is a mental health service that offers brief (one week to two months)
intensive treatment for persons experiencing mental health crises that may otherwise have
been treated in an inpatient ward (Johnson, 2013; Johnson & Bindman, 2008; Lloyd-Evans et
al., 2016; Lloyd-Evans et al., 2017). HTTs are multidisciplinary teams made up of
psychiatrists, social workers, nurses, psychologists1, occupational therapists2, and personal
support workers. They work to divert individuals in crisis from inpatient wards, visiting service
users’ homes or living spaces up to three times per day, seven days a week to provide
treatment and support. Such teams have different names that are commonly used, including
crisis resolution and home treatment teams (CRHTT), crisis teams (CT), and crisis resolution
teams (CRT). I will refer to them throughout this dissertation only as HTTs. In the
psychiatric literature, the people who use these teams are generally referred to as service users

1
Many teams do not have a psychologist. The team I was with only had a psychologist for the last three months
of my study.
2
Many teams also do not have occupational therapists, the team I was with did not have one when I was there
but did have one in years previous.

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but I will adhere to the use of the nomenclature in situ, as others have done in the past (Myers,
2015). This is not meant as a sign of disrespect but as an effort to present the field as it was
experienced (for example, the team almost exclusively used the term patient or (rarely) client to
refer to service users.

The people who use HTTs can be afflicted with a wide array of mental disorders, from
common ones such as depression and anxiety to the severe such as bipolar disorder and
schizophrenia, as well as multiple or comorbid disorders, including personality disorders and in
some cases comorbid substance abuse (although never substance abuse alone) (Brimblecombe,
2001; Heath, 2005; Johnson, 2013). HTTs assess all individuals who present themselves to a
hospital A&E ward, are referred to HTTs by another mental health team (and in some cases,
a GP), or are deemed to be eligible for inpatient treatment by any mental health or liaison
service. The HTT screens the individual, deciding whether they are eligible for home
treatment based on factors such as: Are they a risk to themselves or others? What is their
home situation (are they homeless, do they have gas and electric)? Has home treatment
worked for them in the past? Do they have the ability to function at home? Although there are
other teams that may visit the home, including community mental health teams (CMHT),
only HTTs intensively treat service users in the home, form a central hub within the mental
health system, gatekeep all admissions to inpatient wards, and receive early discharges from
those wards.

Home treatment teams have four main responsibilities across the UK. First, they are
responsible for gatekeeping every person under consideration for an inpatient bed. Second,
they work to provide a softer transition from the ward to the home via early discharges from
the wards and accompanying support. Third, they treat people in their own homes, visiting up
to three times a day and providing a 24-hour service3. Fourth, they tend to continue the
treatment and home visits until the individual is transitioned either to another team or, if their

3
Many teams across the UK have been unable to provide a true 24 hour service and have instead relied on other
services to provide cover during overnight hours Care Quality Commission (2015b). Right here, right now – help, care
and support during a mental health crisis. London, Care Quality Comission,: 16.

11
condition is deteriorating, into an inpatient ward informally (if possible) or via a Mental Health
Act Section.

HTTs have not always been a part of the UK mental health system. They have appeared at
various times since the 1940s but never formed a standard part of the mental health system
until they were announced as such in the National Service Framework (NSF) in 1999
(Department of Health, 1999), and then implemented by the Policy Implementation Guide
(PIG) in 2001 (Department of Health, 2001). The introduction of HTTs was an attempt to
“modernise” mental health care and produce an effective and efficient service, while
maintaining or implementing a patient-centred focus. However, the PIG and NSF were both
thin on guidance for specific team practices, preferring to leave the bulk of the work in
organising these teams to the local mental health services. This created vast differences
between teams and led to difficulty in evaluating their effectiveness (Johnson & Bindman,
2008), opening a rift in the psychiatric establishment (which I cover in more detail in chapter
three) concerning whether or not these teams were effective and what elements might make
them effective (Johnson, 2011; Tyrer, 2011).

What is Currently Known About Home Treatment Teams?

HTTs have a limited base of psychiatric research upon which to draw, which has grown
slightly during the period of my research. There remains very little social science research that
describes the practice of these teams or the experience of their service (G. Anderson, 2006;
Hannigan, 2013; 2014; Hannigan & Allen, 2013; Hannigan & Evans, 2013). Early on in the
history of home treatment, sociologists and anthropologists were involved in writing about
their development and sometimes worked in partnership with psychiatrists in the development
of services (Estroff, 1981; Lemkau & Crocetti, 1961; Scarpitti et al., 1965). I will aim to
develop and examine an explication of the practice of the teams and the experience of home
treatment, both of which are now directly tied to austerity. This is necessary because of the
lack of knowledge and a consensus view on what home treatment is within British psychiatry
and its clear link to austerity. Without going into too much detail here, I will give a quick
summary of the evidence base for home treatment and some of the difficulties with this.

12
The base of evidence the government used to select home treatment as a national service
originated in the 1970s with the “Training in Community Living” (TCL) programme (Johnson
& Bindman, 2008; Stein & Test, 1980; 1985). The government also referenced numerous
replications of the TCL method, including the Department of Health and Sainsbury Centre
for Mental Health sponsored studies in Birmingham and the London Borough of Southwark
(Dean & Gadd, 1990; Minghella et al., 1998; Muijen, Marks, Connolly & Audini, 1992). All
of these studies supported the use of psychiatric home treatment in addition to arguing that, as
a diversionary service, home treatment could lower the use of beds, cost less than traditional
inpatient treatment, and provide an equivalent service to that of an inpatient ward. These
claims were controversial from the very beginning, and HTTs have never been wholly
accepted by the psychiatric establishment (Deahl & Turner, 1997; Pelosi & Jackson, 2000;
Tyrer, 2011; Tyrer et al., 2010).

In creating NSF for mental health, the government relied heavily on a report delivered by the
Sainsbury Mental Health Centre entitled Open All Hours, which has been referenced
extensively by both the NSF and PIG (Department of Health, 1999; 2001; Minghella, Ford et
al., 1998). Little is written about why the government decided to use HTTs, but the name
and contents of this report suggested that it was for the expected cost savings. The report’s
name was borrowed from a popular sitcom in which the protagonist tried to make as much
money as possible in his shop while spending as little of his own money as possible (Lotterby,
1976). The parallels with this protagonist were stark as the report argued for an incremental
reduction in beds to fund the development of HTTs. They claimed HTTs could reduce the
cost of care, allowing for the closing of beds which would then fund their ability to take on
more demand. The evidence for this was a comparison between the Yardley HTT and a
nearby hospital-based service. Taken as a whole, this was not the type of evidence that one
would have expected to form the basis of a national policy. The only randomised controlled
trials (RCTs) available to support HTTs at the time were completed in Australia by John
Hoult et al. (1983) and in the Borough of Southwark by Matt Muijen et al. (1992). The other
studies commonly cited (Dean et al., 1993; Fenton et al., 1979; Pasamanick et al., 1964; Polak

13
& Kirby, 1976; Stein & Test, 1980) were either comparison studies, were not RCTs, or were
not equivalent to the current home treatment programmes. Five years later in an RCT of an
HTT, the authors, including John Hoult, would claim that “no randomised evaluation of this
service model has been carried out in a modern community mental health system” (Johnson et
al., 2005:602). The lack of strong evidence supporting home treatment left the primary reason
for national home treatment as the lure of future cost savings from the teams and the ability to
close inpatient beds (which the government did in droves).

Once HTTs were made a national policy, the lack of evidence created a divide between
supporters and detractors of home treatment (Catty et al., 2002). Sonia Johnson, along with
John Hoult and others, became key figures in defending home treatment, publishing the
aforementioned RCT of the HTT in the Boroughs of Islington and Camden, London
(Johnson et al., 2005). The study revealed that an HTT had managed to reduce admissions to
inpatient beds, thereby supporting the claims of previous studies. Peter Tyrer et al. (2010)
published a controlled study of two HTTs in Wales in which they found a reduction of
informal admissions that came at the cost of a future rise in compulsory admissions. Another
study, which was not an RCT but rather an analysis of routinely collected data and a
questionnaire in Edinburgh, published by Victoria Barker et al. (2011) backed up Sonia
Johnson’s work. A public argument grew out of this and eventually built itself into a full-blown
debate, which I will discuss later. Suffice to say, the evidence to support the efficacy of the
HTT model was disputed and revolved around its ability to reduce the use of beds, cost less
than hospital or similar treatment, and produce similar outcomes.

Recently an effort has been launched by Sonia Johnson, Bryn Lloyd-Evans, and others to
develop a fidelity scale for HTTs to standardise treatment and practice as well as provide
further evidence that HTTs do in fact reduce beds and cost less (Lloyd-Evans et al., 2016;
Lloyd-Evans et al., 2017). Also, there is an RCT of an HTT currently ongoing in the
Netherlands that looks to be the next step in developing the evidence base (Cornelis et al.,
2018). Unfortunately, all of this is occurring under a continued and systemic disinvestment—
despite claims otherwise—from mental health care by successive governments after the 2008

14
financial crisis (British Medical Association, 2018; Docherty & Thornicroft, 2015). As a result
of this austerity, HTTs are being caught up in processes of what Helen Gilburt (2015) calls
“service redesign”, which I will argue is a process of turning the aims of these teams towards
managing the current and increasing austerity within the mental health system.

Austerity
Austere environments and mental health services are nothing new; in fact they are fairly
ordinary. So why then is it necessary to look at austerity? First, HTTs have a special
relationship with austerity; as I have argued above, they are being used to deal with these
increasingly austere environments and this use should be explored. Second, the service users
of the HTT, many of whom are low-income or in receipt of benefits, are broadly affected by
austerity policies outside of those affecting mental health funding, policies which have only
been emboldened since the 2008 financial crisis. The experience of austerity is multiple; it can
exist between state and mental health trust, mental health trust and HTT, HTT and citizen,
or citizen and state. I use the term “multiple” in a nod to Annemarie Mol’s (2002) work on
ontologies and to recognise the complexity and multiplicity of the experiences and effects of
austerity but also as a way to point towards the different lived realities that go with those
viewpoints (Hitchen, 2016; Hitchen & Ulrike, 2014). If this sounds confusing, that is because
it is confusing.

The term “austerity” is used in many different ways and with reference to many different
things. In this sub-chapter, I will lay out how I will use the term and to what I am referring. To
begin with, I will define what austerity is in economic terms. I will then argue that the way in
which austerity was presented to the UK public was with an association to a particular
morality that recast benefit users as suspicious and subject to conditionality. This
conditionality combined with other cuts to associated services resulted in deteriorating
conditions for those who received government benefits or services. I will then argue, using the
social determinants of mental health, that these worsening conditions have actually generated
common mental disorders or increased their severity. Finally, by bringing together the above

15
arguments, I will argue that austerity is something that is lived and not just an economic
policy.

What is Austerity?
Contemporary austerity is an economic theory that suggests that during a recession or
depression the only way to future stability and economic growth is by radically reducing both
public spending—by cutting government programmes like benefits or healthcare—and
government debt. This, allegedly, leads to investor confidence in the country, thereby
producing investment and growth in the economy (Blyth, 2013; Schui, 2014). This theory,
borne out of classic liberalism, views the state as an entity that protects capital and private
property, and leaves “the market” to prosper with as little interference as possible (Blyth, 2013;
Buchroth & Hetherington, 2018). At the core of this belief is a fear of government debt that
has its foundation in the works of early liberal philosophers John Locke (1690), David Hume
(1777), and Adam Smith (1887). These early modern philosophers feared that government
debt would eventually reach such a point that the cost to service the debt would exceed that
which could be raised through taxation, leading to a government default on debt. All three
philosophers were of the opinion that excessive “government debt perverts savers, distracts
merchants, and ruins accumulated wealth” (Blyth, 2013:114).

The impact that these philosophers had on economics is immense, but they were writing in
reaction to the state as they saw it in their time, not the modern democratic state that exists
today. How applicable are these ideas to current modern democracies? These authors were
critiquing states run by monarchs spending lavishly, failures of banks, and other economic
misadventures (Blyth, 2013). Often the failure of a monarch to properly manage a nation’s
expenses led to higher taxes, which led to revolutions and violence. This was not an irrational
fear of government debt and it certainly explains their position against state intervention in the
economy. However, none of these philosophers actually referred to austerity or programmes
of austerity; the contemporary theorists of austerity would not emerge until much later.

16
Contemporary economic theorists, of whom John Maynard Keynes and Friedrich Hayek are
the most well-known, offer the two poles of a bipolar assessment of how to bring a country out
of recession. Hayek and other economists from the Austrian school represent the main
proponents of austerity programmes while Keynes represents economists who believe that the
state can prime the pump of the economy with public spending. The main issue that separates
them (this is of course an over-simplification) is the role of consumption. Keynes believed that
“consumption—to repeat the obvious—is the sole end and object of economic activity”
(1964:104). This meant that spending drove the economy, and the state could help to push the
economy out of a recession by spending and thereby showing other investors that they should
be confident about investing in the economy. Hayek (1945) disagreed; he and others,
including Joseph Schumpeter (1942), argued that ballooning public debt was something that
scared off investors (Blyth, 2013).

For Hayek and Schumpeter, the best thing to do in a recession was to aggressively cut public
spending and pay down the debt, thereby showing investors that there was promise in
investing in the economy because taxes would ultimately be lower in the future (Blyth, 2013).
Cutting back on spending became, under this logic, a driver of expansion in the economy
(Alesina & Ardagna, 2010). Only, if you apply what Keynes says above to this position,
investors would avoid investment because no one else was investing, ultimately shrinking the
economy. Surely there must have been good evidence for so many of the world’s nations to
plunge themselves into austerity post 2008?

Mark Blyth, in his book on austerity, points out that there was “no well worked out ‘theory of
austerity’ in economic thought that extends back in time to some foundational statements that
become more systematised and rigorous over time” (2013:99). Recent accounts of economic
austerity are often highly specific to very particular conditions, not easily generalised, and
poorly thought out (Blyth, 2013; Schui, 2014). In fact, the International Monetary Fund’s
chief economist, Olivier Blanchard, reversed his position supporting austerity, having
understated the damage cuts can have on a weak economy (Krugman, 2015; Plumer, 2012).
Why then was austerity chosen as the policy to bring Britain out of the recession? Milton

17
Friedman once said that the function of economists is “to develop alternatives to existing
policies, to keep them alive and available until the politically impossible becomes the
politically inevitable” (1962:vii). The economist Paul Krugman once said that “conservatives
like to use the alleged dangers of debt and deficits as clubs with which to beat the welfare state
and justify cuts in benefits” (2015:6). The truth is probably somewhere in between the two
points.

The Conservative Party reoriented themselves between these two points when they shifted
towards austerity shortly before the 2010 election. They argued that the former government
had “maxed out the credit card”, leaving a mountain of debt that had to be reduced if Britain
were to inspire confidence and not meet the same fate as Greece (Afoko & Vockins, 2013;
Skidelsky, 2015). With this reorientation came an appeal to a particular set of morals that went
along with austerity. These were revealed in a party document that claimed “ending Britain’s
welfare culture is a moral duty for any progressive government” (Conservative Party, 2008).
Prime Minister David Cameron (2012) would later call his government’s welfare reforms a
“moral mission”, repositioning the goal of the government from mere austerity to rewriting a
nation’s morals—something that would reverberate through service users’ lives.

Austerity and Morality

We talk about moral hazard in our financial system - where banks think they can act recklessly
because the state will always bail them out…

…well this is moral hazard in our welfare system - people thinking they can be as irresponsible
as they like because the state will always bail them out.

-Prime Minister David Cameron (2011:1)

In making the case for austerity to the British public, there was an appeal to the values of hard
work, fairness, shared sacrifice and an obligation to serve future generations (J. Clarke &
Newman, 2012). Implicit in this argument was an effort to, in David Cameron’s words,
“change the way we think about ourselves and our role in society” (2010:1). In changing the

18
relation of the citizen to state, the Coalition Government sought to rid the UK of “freeloaders”
by providing a regime of conditionality that would weed out welfare fraud, force those
undeserving poor into work, and be more “fair” to those who paid taxes (Morris, 2016). In
pursuing their agenda of austerity, the coalition and successive governments recast those
receiving benefits in the Malthusian terms of the deserving and undeserving poor (Harkins &
Lugo-Ocando, 2016). Cameron helped to reinvent this Malthusian conception of welfare that
viewed recipients as a morally defunct, lazy, and undeserving underclass (Harkins & Lugo-
Ocando, 2016; Morris, 2016).

These arguments for austerity and the remaking of the welfare system often made the
“undeserving poor” seem feral and violent, as Cameron (2011) did in the speech quoted at the
beginning of this section. Stuart Hall and colleagues (1978), in a book on the mugging crisis in
the 1970s, drew a link, within discourse about the crisis, between the hard work of some
juxtaposed with the (potential) violence of the undeserving welfare recipient. Hall also
analysed the role of discipline within British society and how this equated generally to a
deference to authority, and for working class people, “a practice of thrift—making do—in the
face of adversity, the self-sacrifices necessary to maintain the collective nature of social life and
organised efforts against the odds” (Hall et al., 1978:143). David Cameron (2009) and others in
the UK government drew on this discipline in their appeal for austerity, threatening the
potential for Britain to fall victim to a similar fate as that of Greece, and everyday people
flocked to this idea. Despite the appeal to the “collective suffering” necessary to avert a crisis,
there was, in fact, nothing collective about the suffering and the effects of austerity have been
unequal, hitting those on benefits the hardest (J. Clarke & Newman, 2012; Schrecker &
Bambra, 2015).

The changes to benefits as part of this so-called “moral mission” were to make welfare for the
unemployed and disabled conditional and based on meeting strict criteria (Dwyer, 2018;
Dwyer & Wright, 2014). These conditions were backed by “a punitive system of tiered
sanctions and fines”(Dwyer & Wright, 2014:27) which, combined with the rhetoric around
austerity and welfare, created a sense of indebtedness to society. Maurizio Lazzarato’s (2012)

19
work on debt and neoliberalism ties debt and morality together, drawing on Nietzsche who
pointed out that guilt was derived from debt. Kirsten Forkert carries this forward by arguing
that “austerity transforms social rights such as unemployment insurance, healthcare or the
minimum wage into social debts; people who benefit from them then become “debtors”, who
must repay their debt through adopting prescribed behaviour, and opening up their lives to
external scrutiny” (2014:49). Recipients of welfare (including those who were disabled) were
essentially locked in a constant struggle to define themselves as apart from those who are
undeserving, while at the same time “being spoken to and treated as citizens of unequal
worth” (Pemberton et al., 2015:30). Consistently dealing with the denigration of their identity
as (disabled) persons receiving benefits leads to humiliation and shame, one of the five
“austerity ailments” that a group of psychologists identified in a report on austerity (McGrath
et al., 2016:1). The other ailments are: fear and distrust, instability and insecurity, isolation and
loneliness, and being trapped and powerless. All of these appeared in some form in many of
the lives of the services users I visited.

Austerity and Mental Health

Austere environments have always been a feature of mental health care from the days of the
asylum (Bailey et al., 2013). Bed levels are, for example, a rough indicator of a loss of funding
in the system, especially post asylum closures. In 1954, there were approximately 154,000
patients in asylums, which constituted 40% of NHS hospital beds, operating on only 20% of
the hospital budget (Gilburt et al., 2014). Levels of inpatient beds have steadily fallen since
that time. Indeed, closures have increased in recent years; between 2009 and the first quarter
of 2018, inpatient beds have fallen by 30%, from 26,448 to 18,082 (Helm & Campbell, 2018).
The ordinariness of these conditions has been ingrained into psychiatrists, one of whom told
me that “rationing comes out of medicine and the NHS is very good at rationing; rationing is
everywhere”. He went on to share his concerns for the future, stating: “I’m very, very,
worried about whether the NHS can continue to be good at it”. The fact that rationing is
considered a part of medicine in general, and mental health care in particular, reflects on the
nature of the conditions under which psychiatrists are trained in the UK. That being said,
funding levels go down and new things are introduced and funded (or defunded), but services

20
often do not drastically change decade to decade in mental health. For example, inpatient
facilities have been difficult and often violent for decades and continue to be (Bowers et al.,
2009; Csipke et al., 2018; Foster et al., 2007; Muijen, 1999). Unlike the steady decline in
mental health expenditures, service users are not static and predictable.

Service users live and breathe the policies of successive governments, especially those who are
on benefits and other supports offered by government agencies (Bhattacharyya, 2015;
Goodley et al., 2014; Mattheys et al., 2017; McGrath et al., 2016; Pantazis, 2015). Many
service users exist in the lowest income bracket, at the periphery of the economy, working
low-paid, “zero-hours contracts” and are therefore acutely vulnerable to economic downturns
and welfare retrenchment (Jenkins et al., 1997; Lewis et al., 2003; Mangalore et al., 2007;
Mattheys et al., 2016). They feel and react to every cut to benefits that occurs (Goodley et al.,
2014). Austerity and economics are tied to mental health as well as population health, as the
policies and actions of governments based on economic theory produce conditions wherein
illness can proliferate (Bambra et al., 2005; Mattheys et al., 2017; McGrath et al., 2016;
Schrecker & Bambra, 2015; Stuckler & Basu, 2013). The deterioration of services and
conditions during the economic downturn and subsequent programmes of austerity have had
an impact on mental health and this impact can be inferred by looking at the social
determinants of mental health (Allen et al., 2014).

The social determinants of mental health are conditions or factors in society that have been
shown to have important effects on mental health, either directly or indirectly (Allen et al.,
2014; Lund et al., 2014; World Health Organization, 2014). These determinants can take the
form of material determinants linked to the material environment, such as environmental
pollution like mould, damp, noise, or crime; psychosocial determinants like loneliness; or
behavioural determinants like smoking, alcohol consumption, or exercising (Allen et al., 2014;
Bährer-Kohler & Carod-Artal, 2017; Mattheys et al., 2016). Importantly, these determinants
are unequal in their effect. For instance, housing and accommodations that are affected by
crowding and/or damp, or have a negative perception attached to them are all linked to
increased mental health difficulties (Dunn & Hayes, 2000; Gabe & Williams, 1993; Hopton &

21
Hunt, 1996; Hyndman, 1990; Krieger & Higgins, 2002). However, if an individual has the
financial resources to comfortably live in accommodations without these issues, they are able
to avoid the negative consequences that this can have on mental health. Thus, many of these
determinants are unequal and are based on a gradient of social-economic status. Those in the
middle of this gradient have poorer outcomes than those above them and are better off than
those below them (Allen et al., 2014; Kosteniuk & Dickinson, 2003; Marmot et al., 2010).

The work of Schrecker and Bambra (2015), Stuckler and Basu (2013), and others has helped
to develop the determinants of health and mental health in the direction of economic systems,
policies, and politics (Ottersen et al., 2014). Economic systems and policies, like the UK
austerity programmes, have deteriorated the social supports for individuals suffering from
mental illness and created more illness (Barr et al., 2015; Mattheys et al., 2016; Mattheys et al.,
2017). Returning to the gradient, those at the bottom have increased drastically since 2008 in
the UK. Households living below a minimum income standard since 2008 have increased by a
third (Padley et al., 2015). Not all of these people are out of work as nearly half of people in
poverty are working (Geiger et al., 2012). The conditionality within the benefits system along
with the instability in low-paid work is driving insecurity and stress in low-income individuals
(Geiger et al., 2012). Income is a major factor in mental disorders, as the gradient shows;
individuals with lower incomes will have more difficulty accessing material and social aids that
might increase their resiliency (Allen et al., 2014; Knapp, 2012). Stable housing is a
determinant of mental health as well; control over housing and control over living space is
beneficial to mental health. Changes to housing benefits have limited the ability of single
people aged 25-34 to claim single-bed flats, forcing them to instead claim a single room in
shared accommodation (Wilkinson & Ortega-Alcázar, 2018). Income and housing together
have a cumulative effect—shared accommodation being less stable and more stressful than
living in a one bed flat—leading to a greater likelihood of the individual suffering from mental
health difficulties (Allen et al., 2014; Wilkinson & Ortega-Alcázar, 2018).

Adding to the above cumulative effect on mental health is the disproportionate effect that
these austerity policies have on the BME community (Bhattacharyya, 2015). Along the social

22
gradient, BME groups are over-represented at the bottom of the gradient in comparison to
white British people (Weekes-Bernard, 2017). This creates a disproportionate exposure to
austerity policies and their subsequent effect on mental health. Which serves to further
intensify the already existing over representation of BME groups within the mental health
system, particularly so in Lambeth (Lambeth Black Health and Wellbeing Commission,
2014). This in turn exasperates long-standing problems that British psychiatry has with
institutionalised racism and a lack of equality in the treatment of BME service users
(Macpherson, 1999; K. McKenzie, 1999; K. McKenzie & Bhui, 2007; Sashidharan & Francis,
1999; Browne, 1997; Davie et al., 2014; Fernando, 2017; Keating et al., 2002; Royal College of
Psychiartists, 2018). In later chapters I will adress the BME community’s disproportionate
experience of the effects of austerity, its effects on their mental health, and how this creates a
further degredation in their lived experience.

These policies have created illness and increased its intensity through their deterioration of
social supports and direct effects on many of the social determinants of mental health.
Individuals already suffering from common or severe mental health disorders can be thrown
into crisis by these changes, or it can slowly wear them down. This slow wearing down
involves viewing austerity and events related to it differently.

The Lived Experience of Austerity

The link between austerity and affect is not the immediate crisis that an individual is driven
into; rather it is the mundane events (linked to various social determinants) that carry on
wearing away resilience. The lived experience of austerity is not crowded with moments of
immense suffering; rather it is a drawn-out process that slowly shapes and reshapes affect. It is
not the discovery of mould that drives illness; rather it is the fifth month of living with the
mould, with no remediation, that drives illness. Austerity is felt and lived, in the simple
everyday events—"quasi events”—that contribute to a slow accumulation of weariness or, as
Elizabeth Povinelli explains,“the violence of enervation, the weakening of the will rather than
the killing of life” (2011:132). Austerity and the advanced retrenchment of the welfare state has
made conditions so difficult so as to diminish the importance of most other matters in an effort

23
to survive (Bhattacharyya, 2015; Goodley et al., 2014). Esther Hitchen (2016) writes about
atmospheres of austerity, which help to reveal how long-term concerns, such as the
anticipation or fear of reductions in benefits, can condition an individual to have an affective
reaction to regular occurrences, such as receiving a letter. It is through the living of policy, the
living of the social determinants of mental health, that austerity begins to have a psychic life (J.
Butler, 1997). Anne-Marie Fortier, in her study on the process of becoming a UK citizen,
argues that “anxiety is [now] an enduring feature of the state-citizen relationship” (2016:8). It
is this anxiety that drives the diminishing of expectations and focuses those in poverty on
sheer survival with the suspicion of more cuts (Horton, 2016). Living under these conditions
wears away individuals over time, eventually driving them into crisis. The HTT is then left to
decode the crisis and attempt to effect change in their life, only this becomes more and more
difficult, as I will show.

Just as people cannot last forever under increasingly difficult conditions, neither can austerity.
Austerity can only last for a certain amount of time before it generates its own collapse; a state
can only cut so much before nothing is left, a plant can only be in drought for so long before it
withers and dies. Austerity also, as this dissertation will show, brings with it a sense of
shortened time, that limits the way that institutions see time and produces time-limited or
“abbreviated thinking” (Hassan, 2003; 2009). Austerity forces a focus on the short-term, with
an anticipated future where austerity is relaxed—only that future is never quite as well
thought out as the present moment. The shortened sense of time comes from an acceleration
of time; doing more things in less time is considered efficient—it saves money and time. It also
comes from one of the basic premises of economic austerity policy which, counterintuitively,
insists that a strategy of severely limiting spending will produce economic expansion (Blyth,
2013; J. Clarke & Newman, 2012). In short, do more with less, or just, less is more. Austerity
is an acceleration of time, as well as a lack of time or, perhaps it is a condition of being short on
time.

Time

24
“The temporal framework we impose determines what we can do and see”
(Adam, 2008:2)

What does being short on time mean? To unpack this question involves bringing time and
temporal aspects of psychiatry to the foreground in this dissertation. Why do this? Time
organises much of what psychiatry does, in ways that can be innocuous or obvious and are
often not engaged with (Chandley, 2000; Donald, 2001; von Peter, 2010). Time is also a
crucial element in understanding the effects of austerity on HTTs and their service users
(Donald, 2001). The choice of temporal frame reveals different issues and different aspects of
psychiatry (Chandley, 2000; von Peter, 2010). Generally, the goal of clinical psychiatry in the
short term, as I observed, was a stabilisation of crisis. This goal is approached, depending on
the disorder, with powerful medications that have quick effects. In the longer term, clinical
psychiatry is about returning the individual to their life in a way in which they can function
from day to day. This can involve medication changes over a span of months to reduce side
effects while keeping the individual relatively healthy. The longer-term goals involve helping
the individual towards flourishing in life and preventing a return to crisis. This includes
medication in addition to other aspects of therapy/support that may help to produce a more
stable psychological growth and recovery. What looks like a linear progression through these
stages can turn into a cyclical process when the temporal frame is extended further. The
revolving door—when service users cycle through the mental health system, never stabilising
enough to spend extended periods of time outside of the system—can only be revealed, and
thereby intervened on, if your temporal perspective allows for it (Donald, 2001; von Peter,
2010).

There are many other temporal elements to psychiatry, from the half-life of sedatives like
lorazepam to the extended effect of an Aripiprazole Depot injection, from weekly sessions
with a psychologist to months spent waiting for the next promising therapy (Matthews-King,
2018). Waiting is a common rhythm within psychiatry—waiting for the drugs to take effect,
waiting for the next appointment, waiting for therapy, waiting for a nurse to take you out for a
cigarette (Lawn & Pols, 2003; Matthews-King, 2018). There are temporal elements scattered

25
throughout psychiatry that, when brought into this analysis, provide a deeper understanding
of service user experience. But time also provides a deeper understanding of how austerity
affects all levels of the mental health system.

Temporal frames can also act as blinders obscuring the long-term consequences of actions (or
inaction); in the case of the present austerity, the focus is on the crisis and not on the long-
term effects of changes that are being made to the system (Adam, 1998a; Hassan, 2003; 2009).
Although austerity is directed towards the future, the focus is on cutting expenditures in the
present which works as a blinder to the long-term consequences of the cuts. It pushes those
consequences into the future, whereby the growth that is theorised to come with austerity will
provide the necessary income to deal with those consequences. For example, by cutting
funding for CMHTs and pouring money into HTTs, the ability of CMHTs to continue the
work of HTTs and move long-term solutions for individuals forward is hampered. This
ultimately creates a greater likelihood of relapse. The way the Trust responds to austerity is
by setting the focus on the immediate and dealing with crisis care at the expense of long-term
solutions, negatively impacting on the system’s ability to make lasting change in individual
lives. To develop this analysis, I rely on Barbara Adam’s (1998a) notion of “timescapes”.

Timescapes contain the concept of a scape, which is a reference to landscape, indicating both
“that time is inseparable from space and matter, and second that context matters” (Adam,
2004:143). There is a multiplicity of timescapes, that are determined by their irreducible
constituent parts, which Adam identifies as time frame, temporality, timing, tempo, duration,
sequence, and temporal modalities (1998a; b; 2004; 2008). Timescapes exist for each
individual person, each service, each institution. They overlap and share elements; they
conflict with each other and these conflicts have real consequences. For instance, the rhythm
that is kept by many tobacco smokers as part of a personal timescape can be interrupted by
institutional timescapes (no smoking on hospital property), which can lead to conflict,
frustration, and even violence (Lawn & Pols, 2003). In Adam’s writing, it is clear that not all
of these elements are evident or important in each analysis; instead she uses them as a road
map to analysing temporal elements, rather than a rigorous formula. Throughout this

26
dissertation, the reader will notice these elements rising to the top time and again, although
reference may not be explicitly made to this roadmap. The most common elements that
appear have to do with speed and acceleration as the HTT I studied faced increased pressure
to move people through the system to create space in the inpatient wards.

Speed
Speed and modern medicine go hand in hand. During the time I spent with the HTT, there
were numerous articles published about “bed blocking” in general medical care. Bed blocking
is when NHS service users are unable to be discharged but are medically able to be, and it
costs the NHS upwards of £800 million pounds a year (Campbell, 2015; Harroon Siddique,
2016). The Trust was meeting regularly at the time of my study with acute wards and the
HTT over what they were calling “delayed discharges”, when service users were ready to be
discharged but were not able to be. The HTT was part of these meetings because of their
ability to accelerate discharges. The concern here in mental health is the same as in general
medicine; “patient flow” must be a priority with limited beds. During my time with the team,
there were numerous occasions when no inpatient beds were available in the borough or even
in the entire country. But what does this have to do with speed? In a report by the Nuffield
Trust on “patient flow”, the comparison is made between patient flow in a hospital and
motorways (Karakusevic, 2016). The choice of motorways as a comparison is an allusion to the
speed at which service users (need to) move through the system. The report begins with a
description of flow and congestion on motorways, ultimately tying speed and space together,
as “faster movement requires more space, and when space runs short, movement will slow
down” (Karakusevic, 2016:4).

Speed, space, and time are all interconnected and continue to be so in mental health care.
Time and space can be compressed to produce speed, intensity, and efficiency. David Harvey
(1989) describes the role time and space can have in such a compression. He points out that
there has been “a transformation of the qualities of time and space due to a monetisation of
social relations” (Harvey, 1989:229). In the case of mental health care, time and space are
monetised and tightly controlled to reduce the cost of care. Recall the comparison with

27
motorways: this is made to draw attention to the space that is needed to enable patient flow.
The point of the comparison is to reorganise space and time to achieve unobstructed and
ultimately faster flow. Harvey has several points that are salient here and worth raising. The
first is that the reorganisation of space and time—the compression of space and time—speeds
“up social processes while reducing the time horizons of meaningful decision-making”
(Harvey, 1989:229). The second is that these changes nearly always happen during crises, and
the third is that “spatial and temporal practices are never neutral in social affairs. They always
express some kind of class or other social content, and are more often than not the focus of
intense social struggle” (Harvey, 1989:239). There is a struggle here, between the team, the
trust, and the service user, all of whom define different things as in crisis or not.

The struggle and the changes in the practice of the team that I chart in this dissertation are
similar to those faced by the team studied by Lorna Rhodes (1991) who analysed speed tacitly
in her study Emptying Beds: The Work of an Emergency Psychiatric Unit. She writes about how the
unit “channeled the energy of staff into an emphasis on speed and an awareness of their use of
time and resources” (Rhodes, 1991:58). This changed the unit’s approach to service users—
diagnosis was useful to get the service users somewhere, but for the most part people had to be
pushed out of the unit into the community despite being homeless. This left psychiatrists to
remark about how the city was essentially the grounds of their psychiatric care centre
(Rhodes, 1991). The living conditions of the service users could not be improved because the
goals of the unit were efficiency and speed, and “staff rarely lost sight of the interplay between
available beds and available time as the measure of their success” (Rhodes, 1991:59). Although
space and time on the ward (as in the Rhodes study) or in the HTT can be reorganised to
produce a compression and, as a result, acceleration, it does not mean that this is without
consequence. As any police officer working on a motorway will attest to, an increase in speed
increases the likelihood of an accident, not that this deters society’s obsession with speed, a
topic Paul Virilio (1986) analysed extensively.

Paul Virilio’s (1986) writings on speed coined the term “dromology”, which was a way of
reading the history of modernity and warfare as a series of inventions that help to compress

28
time and space, producing an obsession with speed. Alongside these inventions came the
“invention of the accident” which led Virilio (1997) to create the “dromological law”, which
states that any increase in speed also increases the potential for standstill or gridlock. For the
HTT, this means that with greater patient flow, there is a greater chance that someone, or
some important aspect of treatment, will slip through the cracks and lead to an accident.
Manuel Castells (1996), Barbara Adam (2004), and Robert Hassan (2003; 2009) all developed
similar viewpoints of the dangers of speed. Castells brought up the contradictory logics—for
instance, we can speed up crop maturation but these crops may then fall to disease or other
failure. Adam saw the pursuit of absolute control over time and space leading to an
(im)possibility, that would ultimately bring with it (un)intended consequences. Hassan wrote
about how with the acceleration of society, the time to make decisions is shortened, and the
temporal frame that decisions are made in is shortened so as to produce an abbreviated
thinking. All of these pathologies of speed become a concern for the HTT as pressure is put
on them to move service users through the team and create beds in the inpatient wards. The
unintended consequences of this speed and related near-sightedness are borne out through the
difficulties that service users have with their environment, difficulties that are not part of the
immediate crisis or are too difficult to fix in the short term. Things like damp, mould, broken
appliances, or other aspects of a service user’s environment that require an investment of time
are swept aside in the course of moving the service user through the mental health services as
quickly as possible, and in doing so creating a casualty of abbreviated thinking. In the
following sub-chapter, I will explore the environment, a landscape that is often a source of
distress that affects service users and is worked within and upon by the HTT.

Lambeth: A Distressing Landscape

The environment and landscape of Lambeth are not neutral; in fact, in this dissertation I will
revise the concept of a therapeutic landscape, and argue that through political, economic, and
social relations as well as the built environment, Lambeth becomes a landscape of distress for
many of its residents. My starting point for this concept is inspired from a warning that
Michael Dear and Jennifer Wolch gave about the potential to create a “landscape of despair”,
which they foresaw as a future “collapse of the human-service system and an abandonment of

29
those in need” (1987:254). The landscape of distress will help to expand on the relevance of
the environment for both the HTT and their service users. It will also allow me to coalesce the
social determinants of mental health that I encountered in the lives of service users into a
usable concept. I will give a short introduction to therapeutic landscapes here and propose
where I will revise the concept.

The majority of the work on therapeutic landscapes views landscapes as encouraging or

promoting health and wellbeing (A. Williams, 2009). The concept was originally developed
by William Gesler, based on landscapes that had a history of healing, like Lourdes, France
(1996) or Bath, UK (1998). It has now spread in use from the construction of therapeutic
spaces in inpatient wards (Curtis et al., 2013) to literary analysis (Baer & Gesler, 2004; Gesler,
2000) to everyday places and spaces (Sperling & Decker, 2007) and further.4 Therapeutic
landscapes have been defined in a variety of ways but they can be considered places where
complex interactions between the material or built environment, social relationships, and the
symbolic environment come together to create a healing place or a place that is conducive to
health and healing (Baer & Gesler, 2004; Curtis, 2010; Gesler & Curtis, 2007; Wakefield &
McMullan, 2005; A. Williams, 2009). Like timescapes, therapeutic landscapes are
experienced differently by individuals; for instance, Lisa McKenzie (2015) wrote about how
council estates can appear to outsiders as dangerous drug-ridden places, but to insiders they
are often places of social solidarity and strength for their residents.

The council estates and tower blocks that rise out of Lambeth have been variously portrayed
as racialised and dangerous places (ASH, 2018a; b; L. McKenzie, 2015). The danger has
lessened to some extent, but the condition of these council blocks is of far greater concern to
those who live there. There is an effort (or rather lack thereof) to let these buildings slowly fall
apart (ASH, 2018a; b). As the council sells the land to developers and residents are decanted,
the social makeup of Lambeth shifts, and this shift negatively affects residents (ASH, 2018a;

4
For a detailed evaluation of this field see Williams, A. M. (2009). Therapeutic Landscapes as Health Promoting Places.
In A companion to health and medical geography. T. Brown, S. McLafferty and G. Moon. Chichester, John Wiley &
Sons.

30
b). Unfortunately, other housing providers are equally as poor; numerous clients of the HTT
had ongoing housing issues like mould, damp, and disrepair. Slum landlords run amok in
London, with little that can be done to ensure basic living standards (Gentleman, 2012;
Lammy, 2018; Wall & Booth, 2015). These are issues that are known social determinants of
mental health and cause undue stress on residents (Curl et al., 2015; Gibson et al., 2011).
These issues along with the changes to benefits, racism, zero-hours contracts, social care cuts,
and other factors contribute to the construction of a landscape of distress (as I argue in chapter
nine). A landscape shaped by the socioeconomic policies of local councils, housing providers,
and the austerity politics of the government: all of these aspects come together to create an
environment that engenders distress, one that is visible and capable of being intervened upon
by the HTT with the express purpose of treating an individual in crisis. The relationship that
the HTT has with the environment and economic policies is one that I follow throughout my
dissertation.

Chapter Outline
Across the timespan of this ethnography, the team underwent a consultation process and
ultimately a process of service redesign by the Trust. Despite this, the ethnography is not
organised in a chronological fashion as much of what happened was at times extreme and at
other points ordinary (though there is nothing truly ordinary about people suffering). Near the
end of this work, the Trust was moving into a further phase of identifying services that could
be cut to create a trust that was self-sustaining. Presumably changes continued, and I merely
captured one frame of time during this process but a long enough one to draw some
conclusions. During my time with the team, the UK underwent seismic change from both a
national election and a referendum to leave the European Union, both of which had some
impact on my fieldwork but do not appear as central aspects to this ethnography.

What is central to this ethnography and what unfolds in the following chapters is a retelling of
the history of home treatment, backed by archival research. This moves away from
established stories that other psychiatrists have told and instead focuses on what the service is
doing now and how it came to be doing this. I also tell a story of adjustment—to the new or

31
renewed demands of a cash-strapped mental health trust, and to the demands that austerity
levels on a life—living with less, struggling to adjust, maintaining a level of illness that is low
enough not to interfere with the basic activities of daily living. I place this within the context
of a landscape that is shifting and increasingly causing distress to those who are living within it.

Chapter two introduces the site of my research in the London Borough of Lambeth, with a
Home Treatment Team from the South London and Maudsley (SLaM) Trust. It establishes
the dimensions and methods of my work along with some of the difficult ethical problems I
had to navigate. Chapter three tells the story of the development of HTTs with particular
focus on the economic logic that grows with these teams across an 80-year span. They are
born out of austerity and developed across the world but regardless of their location, they are
all directed towards limiting the use of psychiatric beds by treating individuals in their homes.
I also look at the austerity policies currently present within the mental health system and
within the UK. From here I begin to describe the current practice of the HTT.

Chapter four begins by describing some of the operating practices of the team combined with
the three foundational concepts within the team: crisis, formulation, and containment. I then
describe the process by which one enters the team through the work of the “assessment and
referrals” sub-team. Chapters five and six both describe the anatomy of a home visit in detail,
from what team members do before they visit, to techniques and practices they use during the
visit, through to returning to the team base and supervision. Chapter seven deals with the
process of the consultation and the team’s adjustment to austerity and changes to the mental
health system. It also deals with how the pressure and acceleration of the system creates
difficult situations with service users and perpetuates difficulties for black and non-white
service users.

Chapter eight explores service user experiences of home treatment with the aid of timescapes.
I track the transitions between personal and institutional timescapes. I then look at the
compression of timescapes and its corresponding impact on non-white, British service users. In
the ninth chapter, I construct a concept to help understand the cumulative effects of austerity

32
and other trends in Lambeth that contribute towards feelings of distress. This distressing
landscape covers the “workfare” state, distressing homes, the local community, racism, and
precarious employment. Finally, I conclude by drawing together different aspects and themes
of my research as well as pointing towards what can be done and where research should be
expanded. I hope that I present the field as close to reality as possible and I try to bring the
mundane into the forefront in various sections, like the following one where I begin by
describing how I came to the research, followed by a description of my daily walk to the team.

33
Chapter 2: Methods

The opportunity to study this particular home treatment team was by chance rather than
design; my supervisor had met two psychiatrists in 2013—whom I will call Aubrey (the
consultant) and Carter (the honorary consultant)—who worked in an HTT they thought was
particularly suitable for an ethnographic study. For Aubrey and Carter, the study would bring
a chance for reflection on the way that they practise, in addition to revealing some of the
contradictions that exist on the periphery of their practice. My supervisor introduced me to
these two psychiatrists in a meeting and asked if this was the type of work I would like to do
for my PhD. I immediately told him yes and refused his offer of time to think it over. I later
met with both psychiatrists in the cafeteria of the hospital where they worked, which at the
time happened to be a few minutes from where I lived.5

At a lunch time meeting, Aubrey and Carter told me about the team and its broad social
approach to psychiatry, addressing as many different facets of illness, distress, and disorder as
they had time to do by utilising a psychiatric formulation. They explained that the strength of
this particular HTT was its flexible approach: a multidisciplinary team, reflective of the area’s
demographics, treating illness in a variety of ways. They worked to reveal the root of
individual distress, develop a plan to intervene in it, begin this intervention, and then
transition the bulk of this work and future steps to the next service. The downside to this
approach was that this flexibility allowed other services around them to have an expanding
influence on how they practised home treatment. Halfway through our conversation, a
consultant with the forensic psychiatry team sat down and took over the conversation. He
told me, while arguing with Aubrey and Carter, that the mental health service fails black
British people like himself on a regular basis. He said, “If you are black and well off you might
have depression, but if you are poor, you either have schizophrenia or bipolar disorder”. What
he meant by this was that rich and middle-class black individuals were presumed (by the

5
I moved out of the area before my fieldwork started.

34
psychiatric establishment) to suffer from depression whereas poorer black people were nearly
always diagnosed with bipolar disorder or schizophrenia. This psychiatrist was implying that
clinical psychiatry carried an inherent bias that saw poor black people as particularly unruly or
having a potential for violence, which translated into a diagnosis that allowed for the use of
powerful medication as chemical restraints for behaviour perceived as unruly or disruptive. In
just one conversation, he had managed to construct a frame for me that I would repeatedly
reference while I was with the HTT. This frame dictated that I would need to pay careful
attention to the role of race and how treatment differed depending on the intersection of skin
colour, class, and behaviour. I was able to take this meeting and shape it into a proposal of
what might be covered within this study.

In developing my proposal for this study, I decided that concentrating on interviewing team
members alone would not provide the data I required to reveal the practice of the team and
the experience of its service users. Interviews with team members alone would reveal what
they thought they were doing in the homes of service users, leaving me unable to confirm this
without also interviewing service users. Expanding the study to interview service users would
be difficult, as recruitment of service users would have to go through the team, who might
then pick specific service users that would cast a particular light on the team. On the other
hand, if I recruited service users on my own, I would have to rely on flyers and word of
mouth, which would limit my interaction with service users who spoke poor English or did not
frequent sites where I would be advertising for participants. I decided on participant
observation as it allowed me to have access to the team and its service users, which would give
me the chance to explain my study, recruit for interviews, and gather a broad range of
viewpoints on the service. The HTTs psychiatrists agreed with this approach and thought
that I would be able to shadow team members and, with time, actively participate in home
visits. With their support, it was possible to develop a proposal with participant observation as
the primary method for data collection.

Participant observation allowed me to enter service users’ homes and observe, interact, and
participate where and when appropriate. This approach also gave me the flexibility to follow

35
issues that were inadvertently brought to my attention, as I detailed above in the chance
meeting I had with the forensic psychiatrist. Having the flexibility to develop my focus as I
went was crucial given the lack of previous work published on HTTs and the variety of
practices found within HTTs as a whole. I needed to look at other research that dealt with
similar teams or fieldwork to develop the proposal further and strengthen my case for using
participant observation.

I used four studies to help develop my own and as touchstones for what I could accomplish;
these included: Emptying Beds: The Work of an Emergency Psychiatric Unit by Lorna Rhodes (1991);
Making It Crazy: An Ethnography of Psychiatric Clients in an American Community by Sue Estroff
(1981); Everyday Ethics: Voices from the Front Line of Community Psychiatry by Paul Brodwin (2013);
and Recovery's Edge: An Ethnography of Mental Health Care and Moral Agency by Neely Myers
(2015). These studies confirmed that participant observation would allow me to capture the
detail necessary to pursue my study. However, I also realised that I would have to expand
beyond these works. I felt that Brodwin’s (2013) and Rhodes’s (1991) work was too restricted
to the practice of a team or ward and lacked a strong service user perspective, whereas Estroff
(1981) was only focused on service users despite having access to the team. Myers’s (2015)
work was more balanced but tended to focus only on service users turned team members. To
capture the practice and experience of the HTT, I would have to straddle both worlds,
detailing the practice of the team while including a significant service user perspective. At the
same time, I also needed to provide context by looking at the socioeconomic conditions that
impacted mental health services and service users, as all of these studies did exceptionally
well. Most of these researchers were, as I would be, stepping into the foreign world of
psychiatry. However, they were still in many ways “at home” whereas I was in a country that
was equally foreign to me; as such I needed to open my aperture wider still.

Despite having a familiarity with some aspects of the UK—as Canada shares some
commonalities although there are some stark differences (for examples, see the British class
system and landlord/tenant law)—the UK was still foreign to me. The UK mental health
system was even more foreign to me, which is why I decided to start with a history of home

36
treatment before I entered the field. For fieldwork, an ethnography seemed to be the best
approach and played to my ability to move through the system reasonably unnoticed, being
that I was a white male from Canada. Generally, British people tend to have a fondness for
Canadians which certainly helped me to gain access to service user homes as a researcher. In
addition to this, being a white male allowed me to go to places where female researchers might
feel uncomfortable or vulnerable, and also allowed me to fade into the background during
Trust meetings. Being Canadian and having a clearly foreign accent also gave me the ability to
ask questions that might have seemed brash or foolish with sincerity and receive sincere
answers. In short, an ethnography was a particularly good choice because it played to the
strengths that my position gave me.

The aim of my fieldwork was to document what was beyond the reach of other methodologies
and other accounts of HTTs. As a methodology, ethnography was well suited to capture the
practice of the team, the experience of service users, a shift in practice, and the austerity and
scarcity driving this shift. For example, when I first spoke to Aubrey and Carter they told me
about some of the things the team did for service users, such as helping them clean their
homes, do dishes, make lunch, do laundry, hang shelves, and more. When I began my
ethnography, these activities happened but not nearly as often as I had been led to believe; the
team often did not have the time or resources to do these things on a regular basis. As a
methodology, ethnography allowed me to compare what was said about the team or teams in
general with what the reality was and then investigate why this was the case (Candea, 2007;
Hammersley & Atkinson, 2007; Murchison, 2010). It is one thing to capture a snapshot, a first
impression of the team, but it is the elements that are repetitious that form the practices,
habits, and routines of the team and the foundation of this study. It was through attending to
the lived experiences of both team members and service users that my fieldwork extended in
length to 15 months, and I began to reveal the ways that austerity and scarcity within the
mental health system had brought about change to the HTT practice and the lives of service
users. Ethnography as a research method and practice has the unique ability to allow the
researcher to link the day-to-day lives and practice of individuals, teams, and institutions to
“local mechanisms by which larger policies or institutions negatively impact health” (Hansen

37
et al., 2013:117). The difficulty with using ethnographic methods is that I am left without the
ability to generalise my findings across multiple HTTs.

There are a few factors that may prevent this study from representing a generalisable model of
home treatment and service user experience. The strongest is a lack of a standard model for
home treatment services, which has left services to differ widely in their application across the
country (Johnson & Bindman, 2008). There are some efforts to standardise a best practice for
home treatment, in the form of a large study undertaken by the Department of Psychiatry at
University College London, but the HTT I worked with was not involved in this process
(Johnson, 2013; Lloyd-Evans et al., 2016). This service is also unique in that the team and
mental health service serving Lambeth are known for their excellence in the treatment of
mental health disorders. It is also associated with a dedicated psychiatric research department
in King’s College London called the Institute of Psychiatry, Psychology, and Neuroscience.
However, this study, although not particularly generalisable, will produce important
information in the aforementioned areas of HTT practice, service user experience, as well as
the effect of austerity on these areas. The case of this particular HTT has a specific “intrinsic
interest” that renders generalisation of this study a secondary concern (Hammersley &
Atkinson, 2007:32).

My aim in this chapter is to introduce the field site by walking the reader through my
approach to the HTT. To do so, I will look at the demographic issues present within the
borough, some of the contradictions inherent in the borough, and what (if anything) is being
done about it. I will follow this up by looking at the NHS foundation trust that provides
mental health services to this borough, including the HTT and how their delivery has had to
change. I will then walk the reader through the hospital grounds and into the team base where
I will describe the organisational structure of my work and the choices and difficulties I had
sampling HTT service users. Following this, I will describe how I went about conducting
informal and formal interviews with staff and service users and how I collected and analysed
my data. Finally, I will use the rest of the chapter to address ethical issues that I had to deal
with in conducting fieldwork in the homes of service users.

38
The Borough of Lambeth, London, UK

This study was carried out in the London Borough of

Lambeth, UK and focuses on one HTT in this area. Lambeth
extends south from the edge of the river Thames to Streatham
and Norwood. It has been a centre for immigration to the UK
since the late 1940s, leaving the borough a diverse area with a
Map of London, Lambeth Highlighted
quarter of the current population made up of black Caribbean
and black African people as well as a sizable Portuguese population (Lambeth Council, 2014).
Lambeth has an estimated population of 310,000 and is “one of the most densely populated
places in the country” with “more than twice the London population density” (Lambeth
Council, 2014:1). Lambeth’s population density is expected to continue to grow over the next
five years and beyond (SLaM, 2014c). Nearly 12% of this population is in constant flux, being
replaced by new residents year after year (Lambeth Council, 2014).

Lambeth, like much of London, contains both affluence and poverty. With gentrification
currently creeping its way through the borough, islands of poverty next to highly affluent
areas have become a feature of the borough. Despite this gentrification and the steady climb in
London housing prices, Lambeth is still the “8th most deprived borough in London and the
14th most deprived in England” (Lambeth Council, 2014:1). It also currently has a per capita
homeless rate double that of the city of London and the most working-age, unemployed adults
in England (Public Health Observatories, 2013). In the UK Peace Index, Lambeth was rated
the second least peaceful area in the UK, in part due to suffering a rate of violent crime over
three times the national average (Institute for Economics & Peace, 2013). Residents of
Lambeth also face a serious problem with a lack of social housing. Since 1997, the borough has
seen a 210% increase in the number of people (21,000) waiting for public housing (Ambrose &
Jenkins, 2011). To make matters worse, one third of children in Lambeth live in poverty
(Lambeth Council, 2012).

39
Why are these demographic indicators important for my study? The World Health
Organisation recently published a report on the social determinants of mental health which
listed a number of factors, spread across the life-course, such as socioeconomic status, access
to both material and social supports, and the level and frequency of stressful events—all
correlated with mental health problems both common and severe (2014). For example,
“prevalence rates [of mental disorders] have been shown repeatedly to be higher in social
groups exhibiting less education, unemployment and lower income or material assets” (Fryers
et al., 2003:236). As a result, residents of Lambeth face a high burden of mental health issues
within the community due to their high rates of child poverty, homelessness, poverty, and
stress (least peaceful borough). Add to this the fact that “the impact of persistent disabling and
common mental disorders is most profound and costly in highly populated, urban
communities” (Hatch et al. 2012:1) like Lambeth, and it begins to paint a picture of a
particularly troubled area. But this problem is not just a temporary one; it is a generational
issue. It has been shown that low socioeconomic status not only brings forth poor mental
health in adults, it also has a lasting and detrimental effect on youth, as “higher rates of
disorder in adulthood are associated with multiple disadvantage in childhood” (Fryers et al.,
2005:10). Childhood poverty adversely affects people in later life, which reveals the problems
of Lambeth to be reproduced across generations, creating an issue that is unlikely to go away
without significant effort by the local authority and the NHS to provide strong social supports,
as considerable evidence suggests that weak social supports are associated with poorer mental
health (Lehtinen et al., 2005). So what efforts are being made by the local authority and the
NHS to strengthen social supports in Lambeth?

The NHS Clinical Commissioning Group in Lambeth has taken an interest in mental
wellbeing in the Borough. One of the reasons NHS Lambeth is proactively trying to address
this is due to its large and growing population of people with mental health issues (Hatch et al.,
2012; SLaM, 2014c). The Lambeth Council cites the claims of the Projecting Adult Needs
and Service (PANSI) system used by the Department of Health that the borough has 35,906
people suffering from mental, personality, or psychotic disorder (2014). The South East
London Community Health Survey (SELCoH), which sampled 1,698 people ages 16 and over

40
from 1,075 randomly selected households in Southwark and Lambeth, found 24.2% reported a
common mental disorder (Hatch et al., 2011). To serve the interest of this population, the
Lambeth Living Well Collaborative was created which was comprised of a group of local
service users and carers working in conjunction with the NHS and Lambeth Council. Their
goal was to “radically transform the outcomes experienced by people with long-term and
severe mental illness, who experience high levels of unemployment and poor physical health”
(NHS Lambeth, 2013:33). The council also introduced a Health and Wellbeing board which
established the Commission on Black Health and Wellbeing which produced their final report
in 2014 (Davie et al., 2014). The reasoning behind this commission was the disproportionate
representation of black and black Caribbean people who suffer from severe mental illness. For
example, it was found that “whilst 26% of people in Lambeth identify as black African or
Caribbean, 50% of Lambeth residents in high secure and 67% in low and medium secure
psychiatric detention are from these groups” (Davie et al., 2014:4). Despite a clear focus on
mental wellbeing and BME mental health by Lambeth Council, the mental health services are
still struggling to cope. Lambeth’s need for inpatient services for severe mental health issues is
double the national average. It has among the highest rate, per capita, of people on benefits for
mental health problems of any borough in London (London Health Observatory, 2011). The
borough is also above the national average on a host of other mental health indicators and has
been among the top boroughs in the UK in terms of mental health expenditure per capita
(Lambeth Council, 2013). That expenditure goes towards an excellent mental health service
provider called the South London and Maudsley NHS Foundation Trust which covers the
entire borough.

South London and Maudsley Trust

The Borough of Lambeth is part of the catchment area of the South London and Maudsley
Trust (SLaM), an internationally recognised centre of treatment for mental health that,
through the lineage of the Maudsley Hospital, draws its historical roots back a century.
Created in 1999, SLaM is an NHS Foundation Trust that provides health care services,
including HTTs, to the surrounding four boroughs. Their objectives are to provide the best
quality of care to the population they treat; translate high quality research into practice;

41
promote recovery, social inclusion and mental wellbeing; and respond effectively to the
changing environment (SLaM, 2014b:1). These objectives are geared towards responding to
the mental wellbeing of the population in its catchment area. As the Trust is not capable of
making changes to many of the social determinants that drive mental ill health across the
borough, the services are to some extent designed to contain and treat the symptoms of these
determinants. These determinants are identified in the Trust’s policy documents as “pockets
of high deprivation and poor health; [with] many people subject to factors that adversely affect
their health, including unemployment, poor housing and poverty (SLaM, 2014c:3)” and are
studied extensively by members of the Trust (Hatch et al., 2011; Hatch et al., 2012).

As an organisation, SLaM is unable to produce change in their environment without support

from local and national government strategies, and yet they are facing increasing demands on
their services year after year. Due to an “increase in acute/forensic bed activity and
residential/complex placements outside the Trust” (SLaM, 2014a:29), SLaM has been
running an increasingly high deficit. As a result of financial pressures and their relative inability
to effect change in the borough, they have been forced to rethink the way they deliver
services in the community. This has led to an open admission that their “historic models of
service delivery are unsustainable in the face of financial challenge, societal change and
demographic shift” (SLaM, 2014c:3).

This change in service provision is affecting all levels of the organisation; however, perhaps
the most affected are the HTTs. Primarily, the financial concern is with the high level of
placements outside of the borough, but with no funds to increase beds within SLaM, the onus
falls on pushing treatment further out of the hospitals and “ultimately centre it in the homes of
service users” (SLaM, 2014c). This has led the Trust to review the “function and capability”
of HTTs in order to produce more capacity (SLaM, 2014a:97). As part of this review, the
Trust made the decision to scrap the original Adult Mental Health model of service and make
big changes to the pathways of care, focusing on home treatment as a way to both produce
excess capacity within the inpatient wards by expediting discharges and to group the
assessment functions of all the Trusts HTTs, the bed management team, and the Place of

42
Safety within the same physical area. I followed this process and cover it in more detail in a
chapter seven. Gaining access to the Trust’s decision-making and management system atop
home treatment was difficult.

Initially, I wanted to have more of an involvement in the ongoing discussions and working
groups focused on changing the home treatment services, but I was for the most part held at
arm’s-length by the Trust. On numerous occasions, I was told that I could not attend these
meetings, some of which were on hospital grounds while others were further away. There
were a few related meetings I was invited to but unable to attend, due in part to long-distance
travel. This was despite both the CSL and Consultant working to have me attend some of
these meetings. I did ask several times to meet with and interview senior trust members but
was told to contact them again the next month and so on, until my time with the team ended.
In the end, I was refused a meeting with the senior manager, then at the last second was
invited to sit in on a meeting with the senior manager, and then I was told that I was going to
present on my findings without any foreknowledge of this presentation. Of the few meetings I
was able to attend, most were held on the grounds of the South London Hospital, home to the
HTT with which I worked.

South London Hospital

As you approach South London Hospital, the first things you notice are the red brick walls
and the magnolia-coloured modern buildings. Across the street is a communal garden,
apparently maintained by service users from the hospital, though I rarely saw this happen.
Instead, the garden was more a place for people to sit and wait for appointments or, since the
Trust banned smoking on the hospital grounds, it has become a smokers’ hub. Service users
could occasionally be heard or seen yelling, screaming, or mumbling; in some respects, the
space in front of the hospital was a normalised space for acting crazy (Parr, 1999). Sometimes a
service user sung the theme to the Lion King as loud as possible to jolt the odd passerby or as
a salute to the morning sun. Turning into the hospital, you are struck by the juxtaposition of
modern buildings lined along a short road to the right, and to the left, a Victorian guard house,

43
Victorian era wall, and large Victorian building. Much like this exploration of home treatment,
the past is very much felt in the present.

The Victorian buildings are evidence of a former hospital on these grounds, built in 1871 to
treat smallpox, scarlet fever, and typhus. It is surrounded by large walls, some of which date
back to the original Victorian Fever Hospital. The only pictures I saw of the original hospital
were in the board room where meetings were held with Clinical Service Leads from the
various services distributed throughout the hospital grounds and beyond. Most of the buildings
from the Victorian hospital had been torn down and replaced with purpose-built wards and
offices set out in long buildings with shiny silver roofs and magnolia bricks. These buildings
housed seven inpatient wards including: a rehabilitation ward, early intervention ward, triage
ward, male ward, female ward, psychiatric intensive care unit (PICU, pronounced “Pee-Q”),
and an overspill ward/former forensic unit. The buildings also house outpatient treatment
units, a cafeteria, several different psychiatric outpatient programmes, a pharmacy, and office
space. In a rectangular building tucked across from the Triage ward and its steel box on stilts
containing a garden space for the ward, is the building that houses a forensic service, Approve
Mental Health Professional (AMHP, pronounced “amp”) service and the home treatment
team with which I spent my time.

The Home Treatment Team Base

I spent roughly four days per week with the team and carried out participant observation in
the homes of service users, in five inpatient wards, five Community Mental Health Teams
(CMHT), three hospitals, several Trust meetings, a job centre, a laundromat, a mental health
drop-in centre, several public parks, staff pool cars, one police cruiser, and, of course, the team
base. I carried small journals with me in the team base, taking notes and writing down
conversations that took place. When I was out on home visits, I waited until I got back to
type up my notes on a small computer, in between eating lunch in the kitchen or the meeting
room.

44
The small kitchen, with a table, two chairs and a few things you might find in a kitchen, is
located across from the locked door through which I entered. This was the hub for office
gossip. It was also a hiding spot during clinical review. To the right of this room were two
double doors that stood open all day, save for when a handover meeting or clinical review was
in process. The meeting room itself was a large rectangle with computers lining half the walls,
lockers on the left side and several locked cabinets on the right, one containing medication,
the other containing the PRN (a medical term that stands for the Latin “pro re nata” which I
was told roughly translates to “as and when needed”) medication—a collection of
benzodiazepines and sleeping pills. You can tell by the number of heaters and fans that the
room was too hot during the summer and too cold during the winter. There were 14-16 chairs
at any one time in this room with nearly half being grouped around a central desk. By and far
the most important thing in the room was the board.

For the uninitiated, the board simply resembled an excel spreadsheet, with wobbly lines in
some places and red, green, and yellow magnets on it; but it was anything but simple. The size
of the board and the intensity with which people stared at it made it resemble a great work of
art. Everyone who walked into the room instinctively turned to it, scanning for issues, missed
visits, telephone calls to make, work to do, or, as I found myself doing many times, just staring
in its direction and pondering the lives of various service users. The board could hold
information on 36 people with another few held on a separate smaller board for a total of 42,
which is capacity for the team. This was the organisational device within this team and for the
most part, it was an organisational device for my study.

The board revealed the name of the service user, date of arrival, location, rate of visit, visiting
information, next visit, and a blank space for the names of those visiting. This allowed me to
figure out who I wanted to see and who I would have to ask for a home visit. I listened
carefully to handovers, jotting my own notes about each service user named on the board to
help make these decisions. I worked closely with many members of the team and a few on a
regular basis. I sat in on home visits, clinical reviews, handovers, inpatient handovers,
discharge meetings, mental health act assessments, joint reviews, job centre appointments, a

45
police interview, a presentation from a drug company representative, and countless informal
discussions. During this time, I spoke to and interacted with psychiatrists, nurses, social
workers, personal support workers, pharmacists, care coordinators, general practitioners,
approved mental health professionals (AMHP), police officers, family members, service users,
medical and nursing students, and many more. I developed a good relationship with three
psychiatrists who were able to reveal some of the mysteries of psychiatric practice to me. In
total, I went out for at least one home visit with every member of the team save for the
psychologist who was only hired at the end of my time with the team and another member
who was hired around the same time. I had many conversations and experiences that built a
reliable picture of what it was like to be a team member, what things affected their practice,
and other small but important details.

Service users, on the other hand, were difficult to see on a regular basis. In fact, unless I was
working with the team 16 hours a day, seven days a week, I would not be able to see and hear
every aspect of the treatment of one individual. I did manage to visit service users in every
corner of the borough based on the grid co-ordinates on the board that referred to a map of
the borough. The map hung on a wall adjacent to the board and was more than a decade old.
The board was also a source of basic information for the service users; it listed if they had a
dog or cat, if they needed to be visited jointly or could be visited alone, if HTT staff needed
to buzz in or call ahead, and also if only male or female staff and occasionally black or white
staff could attend. The board would also list telephone calls to be made and the date of the
next joint review and team conducting the review.

The team worked from the board; it defined the world outside the team, where people were
spatially located throughout the borough and it also defined how well service users were
doing. A circular green magnet usually indicated if the individual was doing well and was on
alternate visits or perhaps was only visited once every couple of days. A circular yellow
magnet indicated the individual was seen every day, once a day. The circular red magnet
meant the individual was seen twice a day. Assumptions were often made about how well (or
unwell) the service users were doing based on how many times they were visited a day and

46
the presence of the green, yellow, and red magnets. There were signs that this board might be
about to be replaced; three months into my fieldwork two giant LCD screens were installed.
However, 12 months after two huge TV screens were installed and positioned to replace the
board, the board still stood—albeit below the screens and propped up against the wall but it
was still in use. Despite these technologically mediated attempts to replace the board, it had a
staying power. There was something distinctly tactile about the board that prevented it from
being replaced; perhaps it was its simplicity and effectiveness. Perhaps it was the amount of
pondering, staring, frustration, and release (when particular names were wiped off the board)
that it brought, but it is fair to say that it is probably still hanging in one form or another, just
as integral to the daily routine as it was to mine.

Unbeknownst to me, I looked like I belonged from day one—showing up wearing a buttoned-
up, plaid, collared shirt and jeans made me look like every other mental health nurse. Despite
this, most service users could pick out nearly instantly that I was not a part of the team; some
assumed I was a doctor as I was doing research and was male. I always took time to explain
my position as a researcher and the fact that I was not a mental health professional. I would
begin each day by figuring out who I wanted to see and if that was possible, if the team
member was willing, and if the individual was open to being seen by me. It was not always
possible to see particular service users on specific days, nor was it possible to visit them on
consecutive days. The original design of my introduction to service users had to be scrapped
early on. Most times it was not possible to call ahead and ask if I could see the individual.
Instead, I would be introduced on the doorstep and explained the study after the home visit
was completed. It was a difficult process; I had to introduce myself, run through a one-minute
summary at the door, be invited in, and then try and develop a rapport with the individual,
explain the study in three more minutes and then hope to be able to come back to fill out
consent forms. I signed many individuals up to the study but failed to get them to sign up to
the interview or to sign the documents as I was unable to see them afterwards. Only three
people turned down being part of my study. The actual development of a sampling strategy
was challenging without the ability to pinpoint the individuals I wanted to see and make sure I
visited them on the day, while simultaneously not disrupting the work of the HTT.

47
Sampling a Home Treatment Team and its Service Users
In an ideal environment I would strive to capture a sample reflective of the demographics of
Lambeth, but this was a mental health service geared towards shorter term involvement with
service users. The team turned service users over quickly and selecting them based on
demographics would have disrupted my ability to do fieldwork. I had to fit into the team in a
way that suited them and did not overly burden some members of the team. As a result, I was
not able to pick and choose my sample as closely as I would have liked. There were also
factors that created an overrepresentation of bipolar disorder that I was not expecting. Manic
episodes could make people very open and comfortable with talking about their difficulties
which made them easier to recruit as opposed to those suffering from treatment-resistant
psychosis, where gaining their trust over multiple visits was necessary but difficult to arrange. I
did try and keep my own statistics on who came through the team, but was unable to keep
these accurately. I tried to access this information from the Trust, but unfortunately one was
required to be an employee or researcher contracted with the Trust in order to access the
database. I was faced with great variation in experiences and participants, so I applied the
logic of maximum variation sampling (Hoepfl, 1997): “any common patterns that emerge from
great variation are of particular interest and value in capturing the core experiences and
central, shared aspects or impacts of a program” (Patton, 2002:235).

Originally the team was going to explicitly agree to each service user I saw, and to a certain
extent they did as I had to get their agreement to go out on home visits. But this was not as
tightly controlled as I expected. The team was very open in all of its practices and included
me in many different scenarios and activities. It was quite difficult to see the same service user
multiple times in a week as staffing issues, routes, allocations, and no-shows tended to frustrate
my efforts. That being said, I did get to see a wide variety of people suffering from a wide
variety of disorders. I interviewed individuals with depression, psychosis, bipolar disorder,
anxiety, PTSD, personality disorder, and borderline personality disorder. The ethnicity of my
sample roughly matched that of Lambeth as a whole. The gender balance was also quite good.
In terms of team members, I was able to work with almost all of them and some bank/agency

48
workers. I was told by the consultant that my easygoing nature, sense of humour, and ability
to put people at ease worked well, both in my ability to fit in with the team and my ability to
develop a rapport with service users.

Interviews with Service Users and Team Members

This rapport that I developed with service users and team members allowed me to carry out
many informal interviews as well as some formal interviews. Informal interviews were
conducted with team members on a regular basis in the car, walking, or on the tube on the
way to or from a home visit. Occasionally we would have informal chats while having lunch or
waiting for police officers or an ambulance to arrive. These were typically unstructured
moments that helped to fill in gaps in my knowledge or were times when people were
explaining what was happening to me (Kienzler & Pedersen, 2007). I had numerous informal
chats with members of different teams who knew I was a researcher and were told about my
research while waiting for service users to arrive. I often asked for more information or a
summary of a service user’s condition as we traveled to see them or before I set off to
interview them in their home. All 20 formal interviews with staff members were done at
moments during the day in the team base when they had time. I often booked interview
rooms or used various areas of the team base.

Formal interviews with home treatment staff were structured based on an interview protocol
that I developed but questions were also asked based on the experience that I had in the field
with the individual. I would use particular home visits or events with the individual being
interviewed to draw out aspects of practice that I found difficult to access otherwise (Kienzler
& Pedersen, 2007; Patton, 2002). For example, there were no set practices for what was said
or covered by a home visit; asking team members to walk me through how they would
conduct a home visit while using a vignette to give them a place to begin was useful in
revealing an anatomy of a home visit. I was also able to explore the effect of stress, emotions,
transference, and feelings that came up in these encounters of which I was a part. Surprisingly,
asking whether it was a stressful job rarely elicited a response but asking if it was an emotional
job revealed a way of navigating transference and a preference among some team members to

49
see depressed patients first and save manic patients for last so that they could get a bit of a
boost from the transference. With semi-structured interviews, I was able to access privately
held perspectives that provided insight into how team members viewed the actions of the
Trust, team members, and supervisors. My interviews with the consultant psychiatrist and
Clinical Service Lead (CSL) were able to give me insight into the unseen duties that go along
with managing a team and dealing with the demands of other services and the Trust itself.

As Estroff (1981) and Larsen (2002) observed, the stronger the rapport with a service user the
more relaxed and willing they are to engage in more in-depth conversations and interviews.
This was true of my research as well, and it sometimes took me multiple visits across one or
more periods of treatment to build that rapport. In other cases, service users were excited or
wanted to speak to me about particular things that bothered them about the way they had
been treated. Experience communicating with the service user also provided me with a good
baseline of their behaviour, as well as body language. With that baseline established I was able
to tell whether they were nervous or agitated during the longer formal interview. It also
allowed me to move the conversation along if the service user got fixated on a particular
distressing topic or memory. Although these interviews covered topics that were sensitive and
distressing, many of the service users thanked me for listening to them after the interview
ended. For some this was the first time or a rare occasion when an individual sat and talked at
length about their experience of the system and the things that had bothered them.

Interviews with service users gave me the ability to collect narratives of treatment and
suffering from service users that were otherwise obscured by the demand for symptoms and
clinical elements present in the conversations that practitioners have with service users
(Martin, 2008). My interviews with service users were conducted alone in their homes, often
when the home visits were conducted and often after home visits had ended. I modified a
version of the McGill Illness Narrative Interview6 protocol to fit the parameters of my study
(Groleau et al., 2006). I tried to avoid triggers that might have been particularly painful to my

6
The modified version of the McGill Illness Narrative Interview can be found in the Appendix on pg. 295

50
participants by developing a rapport and a base of information. They were provided the option
of a break or halt in the session. By interviewing service users, I was able to gain an
understanding of what brought them to crisis, how home treatment was able to help, and what
could have been better. I did have some informal interviews with service users but these were
within the structure of a home visit and with another team member. Occasionally, I would ask
questions that were relevant to treatment and participate in the home visit but this was more
participant observation than informal interview. These interviews proved critical in my
analysis of the data and played a large role in directing the focus of some of these chapters. All
interviews were recorded, transcribed and then destroyed. They were then analysed along
with the other data in NVivio 10.

Data Collection and Analysis

As I noted before, I collected data across numerous locations that were concentrated in three
separate mediums. I wrote notes in journals when I was in the team base, in trust meetings, or
across the hospital site. I took notes after I returned from home visits as soon as possible on a
computer and in detail. I also recorded my interviews and transcribed them. I wanted to keep
all identifiable information from appearing in my handwritten journals, but it quickly became
difficult to do this. I needed to know who I was going to see and a little about them, so I could
make (1) an informed decision to go see them, (2) ensure that it was all right for me to see
them, and (3) be aware of some of the potential risks. In the end, I used first names and last
initials to identify people about whom I wrote notes to be able to then create a searchable
database. To begin processing this information, I digitised my notes from the journals,
transcribing them into Word documents using a speech-to-text programme. I then used
NVivo to construct a database that utilised all of this data and organised it, so it was possible
to cross-reference the setting, team member, and service user independently. This cross-
referencing system helped to shed light on specific individuals and on practices that were
contingent to settings.

The next step in this process was to micro-code three months’ worth of notes and journals.
This process was based on the points of interest that I observed when I was with the team. I

51
was looking specifically to bring out elements of the practice of the team, the experience of
the service user, and aspects of the social, political, and economic environment that affected
service users and the practice of the team. I tried as much as I could to take an inductive
approach within those parameters. I first assumed that the home would play a large part in the
analysis; the micro-coding and later coding of themes revealed that the home had a small
presence in my data. After I micro-coded three months’ worth of data, I used the NVivo map
tool to work with these codes, first creating groups of similar codes that formed discrete
themes. These themes were then inserted onto the map and connected with the nodes.
Following this, I organised these themes into groups that gave me detailed thematic groups
that eventually became chapters. I then coded based on these themes and some other outlying
codes to capture interesting themes that I found in later areas. I wrote memos when I found
interesting connections or patterns within the theme. I was then able to cross-reference the
themes with individuals and settings which gave me a database that could then answer
questions. Finally, I added in the interviews and consultation documents, which shed more
light on the themes once they were coded, and revealed in more detail the relationship of the
team and their experience with speed, acceleration, austerity, and other elements.

I used a recursive process to go back over my themes and the data collected. The addition of
the data from the interviews and consultation documents helped to refine the themes and
round out the analysis as things that I identified in the data appeared again in the interviews,
sometimes in more interesting and detailed ways then the day-to-day notes that were coded.
Overall the process was long and intensive and carried over into the writing, as it should
according to Virginia Braun and Victoria Clarke (2006) who have written several excellent
guides on doing thematic analysis that I have used as a basis for organising my analysis (Braun
& Clarke, 2014; Braun et al., 2014; V. Clarke & Braun, 2014).

Ethical Issues and Responses

The following section will cover ethical issues related to this study but before going over
these, it is necessary to briefly outline the process for ethical approval. The process took
around three months and involved detailed revisions of my protocol and NHS documents, and

52
multiple meetings with the principal gatekeepers of this study—the consultant and honorary
consultant psychiatrist. The consultant psychiatrist gave me feedback on my study design to
make sure that I could be accommodated by the team. I was also able to get feedback from
the FAST-R service that allowed for the insight of service users on the design of this study
before it was put through the research ethics panel. The study was approved by the NHS
Stanmore Research Ethics Committee as well as the SLaM R&D Department and had the
full support of King’s College London and SLaM.

There were a number of ethical concerns which I addressed at the outset of the study, some of
which are worth repeating here. All information collected on team members and service users
as well as any direct quotes or anecdotes have been stripped of identifying details.
Pseudonyms have been used for all team members and service users. No potentially
identifiable situations or anecdotes have been published without explicit permission from
participants. All participants have had the ability to withdraw from the study at any point. I
decided against using photographs of my field research as it would have revealed which HTT
I was working with, as well as revealing which service users I was working with to the team.
There was also an additional concern that came out of contemporary events surrounding the
work of Alice Goffman and the ability of journalists to track down and interview her
participants that influenced my decision not to use photographs (Lewis-Kraus, 2016). Many of
my other concerns with ethics were adequately dealt with or did not come up. Instead of
going over these, it is worth taking this space to go over some of the unexpected ethical issues
that did come up.

I did anticipate that during the participant observation period of my research I could be
diminishing the effectiveness of home treatment by taking the spot of another team member.
At the time, I assumed that because team members go on home visits alone, it was unlikely to
cause a difference. Returning to this now I think that there were certainly moments when my
presence may have taken away from the service that the individual was getting based on it
affecting the depth of understanding, rapport, and ability to direct questions towards particular
goals. I also failed to provide the same quality of back-up and follow-up questions that another

53
team member might have. That being said, as I observed I also learned how to do this; as a
result I began to excel at exploring aspects of the service users’ experiences that were
important to capture by team members.

While at times I might have diminished the benefit of home treatment, there were other times
when I certainly added to the effectiveness of home treatment, at some points providing some
much needed relief for service users who felt as though they were not being listened to or did
not have the opportunity to think through their situations at the length that is possible while
doing a long-form interview. Many of my participants told me that through talking about their
experiences, they gained something. Arthur Frank, drawing on Mikhail Bakhtin, stated that
“stories, as dialogue, do not present as self formed before the story is told. Rather in stories the
person becomes for the first time that which [she or] he is—and we [as researchers] repeat"
(2002:115). Sometimes years of difficult memories were brought up and talked through only
for the participant to express surprise at the end that it had not affected them as they would
have expected. There is a literature arguing that there are therapeutic aspects of qualitative
interviews (Murray, 2003; Rossetto, 2014), that interviews can provide, for example
“empathetic listening, curiosity in the client experience, and acknowledgement of the client’s
experience of self-worth and self-determination” (Shamai, 2003:457). I tried as much as I could
to provide acknowledgement of my participants’ growth, reflecting and reframing their
experience as resilience in the face of great difficulty. One service user referred to herself as
damaged goods, and had never revealed that she thought of herself this way, but she realised
that it was the wrong narrative, and that she had recovered her ability to do work and do the
things to make her feel more like herself again.

I did have to adjust or in some cases readjust my practices to account for some issues I had not
anticipated when I received my ethics clearance. The difficulty of adding another layer of
work onto the already strained team members by asking them to phone the service user and
ask them whether I could tag along made adherence to this problematic. I felt at times that
this was burdensome on the workers and I did default to doorstep introductions. For the most
part, I think once I wrote out, memorised, and mastered the short research pitch and the

54
longer three-minute research pitch, I was able to better inform my participants. In the cases
where I was not able to return to do the paperwork or to finalise consent, I have not used that
information in the dissertation. I did use this in my analysis, in terms of coding it and analysing
it, but all of the anecdotes, quotes, and research in this dissertation had explicit informed
consent. One of my participants, after several days of discussion, consented verbally in front
of a psychiatrist who agreed with me that the woman had capacity to consent and did indeed
consent.

Looking back on this study, there are particular ethical concerns that I did not realise would
be difficult to navigate or would impact me the way they did. For one, not being able to read
the service users’ notes or risk assessments made it significantly more difficult to know what I
was walking into for home visits or for interviews. This gave me a bit of heightened anxiety at
times as I was unaware of what I might encounter; this anxiety could carry over into the visit.
As I got comfortable, that anxiety did diminish but I still ended up in situations in which some
team members would not have put themselves. I think it should be noted that I am a white
male and at the time weighed in at 220 pounds and stood 5 foot 11 inches tall; I was able to
place myself in positions where I felt comfortable in which others might not have felt
comfortable. My gender certainly allowed me to sit alone in a room, out of reach of the door,
with service users who had a violent history. I think I took risks that I should not have taken,
being that I could not adequately prepare myself by reading through service user notes to
attain a deeper understanding of the situation. There is a trade-off that occurs between the
safety of the researcher and the privacy of the service user that I think is fair, given that the
researcher does not have to be there, whereas the service user is receiving help and as such has
a right to their privacy in doing so. Nevertheless, it still leaves the researcher in a potentially
vulnerable situation. I did suffer other effects from the research, some as benign as leftover
transference from home visits or interviews that took some time to shake off. Other emotions
were not so easy to “shake off”.

One aspect of this research that I did not put into my ethics application (and I do not think it
should be required), was the ability to make sure that my emotional health and welfare was

55
taken care of. This is not a common request of ethics committees, nor should it be. It would
add one more item to an already long process and would also preclude some people from
doing research due to institutional issues that cannot be circumnavigated. In my case, I fought
long and hard to have individual supervision by a psychotherapist/counselor with whom I
could talk to about some of the more challenging or emotionally disturbing elements of my
research. In the end, my institution provided me with group therapy with several other PhD
students who were struggling. I was the only person who was there to talk about the
emotionally troubling aspects of my fieldwork, so I became the “story-a-week” guy. It was
barely useful and I had to continue to fight to get one-on-one supervision which was finally
made possible in the last few months of my research.

I struggled through my fieldwork dealing with anxiety and depression that would return again
after my fieldwork and drag out the completion of this dissertation. I am not alone in my
struggle with fieldwork (Belgrave et al., 2002; Dickson-Swift et al., 2006; 2007; Lee-Treweek
& Linkogle, 2000; Rager, 2005a; b; Watts, 2008) and the emotional difficulties that can come
with being involved in such difficult work. It did give me a better understanding of the
difficulties of working fulltime in a mental health team and receiving little supervision. It also
may have made my study drift towards the resource-scarce, austerity frame in which it
currently sits. My struggle for support and other personal events during or just before this
fieldwork had an effect on how I came to think about my fieldwork. For instance; my dog
died in my arms, my closest relative and mother figure in the UK passed away, and my wife
lost sight in one eye for a month. I had multiple difficulties with housing including taking a
landlord to court. I had a consistent lack of funding and struggled to pay bills. Many of these
difficulties mirrored the austere conditions of the service users with whom I was working.
These conditions, and the frustration and suffering they caused me, certainly impacted the
focus of my study.

There is a place and a space from which this study was written and it was partially a distrust of
bureaucracies and a learned reaction to fight for every scrap of help that you can get. If that
comes through in this thesis, it can be accounted for here as a point of departure but also as a

56
reflection of the difficult nature of being a researcher in the academy today. In short, although
my ethical review made me ready to protect those with whom I was working while I was
collecting data and doing my participant observation, there was no ethical process that looked
at my own safety and mental health in a similarly protective fashion. I now find that ethically
problematic. Regardless of my stance on the way my own mental health was dealt with, it is
history now, just like the next chapter.

57
Chapter 3: A History of Home Treatment: A History of
Austerity?

The history of home treatment in psychiatry spans more than 80 years7 and three continents.
This study looks primarily at one home treatment team in Lambeth that was introduced, along
with 335 other HTTs across England, in 2001. It is necessary to look back in time and unravel
how the development of home treatment and related therapeutic approaches, both
internationally and in the United Kingdom, have informed its current use. Much of the history
I will tell still resides in archives in the USA, the UK, and elsewhere, and those who had
begun to outline it before (Brimblecombe, 2001; Glover & Johnson, 2008; Heath, 2005) often
left out the inherently social, political, and economic nature of such a history. I argue in this
chapter that home treatment is entangled with austerity and produces an economic logic that
can instruct its use and tends to govern the way that it is deployed in present day Lambeth.

To connect home treatment with austerity, I will move through four separate steps that, when
brought together, illuminate this link. The first step will introduce an economic logic that is
attached to home treatment through its early development. The second step will posit that
home treatment is not a standardised practice, but is in flux. The third step will look directly
at some of the facets of austerity policies within the mental health services which have a
trickle-down effect on home treatment. The fourth step will outline some of the austerity
policies outside of mental health trusts that have begun to have an effect on mental health and
act to further constrain and pressurise treatment. Finally, I will combine these four steps into
an argument that links home treatment with austerity.

Home Treatment and an Economic Logic

The first step in linking home treatment to austerity involves identifying a specific economic
logic that has developed with home treatment services throughout their history. This logic

7
If you include Gheel and other residential programmes, it spans hundreds and hundreds of years.

58
insists that by relocating psychiatric treatment to the community and ultimately the home,
beds that would be used by patients are freed, as they now reside in the community which
results in a reduction of cost. Patients are diverted away from the ward and instead treated in
the home, reducing costs by occupying less beds. This economic logic that grows with home
treatment is often, if not always, explicitly stated within most studies, reports, and other
literature on home treatment. This is not to be mistaken for a grand meta-narrative like
Andrew Scull’s economic argument for the rise of community care and decarceration; this is
an economic logic that is attached to the use and development of home treatment as a service
(Scull, 1977; 1985; 1989). As this logic develops over time, the focus of home treatment shifts
from treating the patient in the home to training the patient in everyday living as an attempt to
create further reductions in cost over time.

My historical and archival research suggests that home treatment, borne out of austerity,
becomes a service that is consistently directed towards the reduction of bed use and the
reduction of cost. Though not all historical HTTs are specifically motivated by concerns of
cost or systemic austerity measures, the economic logic still remains a defining feature of home
treatment as a service. To explore this argument further, I will begin in Amsterdam with the
birth of home treatment. I will then follow the growth of home treatment in the 1940s to 1960s
to England and then to North America, where I will foreshadow the inclusion of training
patients for better outcomes. In America during the 1970s, I will look at the most influential
team in Madison that developed a training programme paired with the installation of values to
further reduce costs and resource use. Finally, I will follow the replications of the Madison
team back to the UK and point out the slow loss of fidelity over numerous replications.

Austere Amsterdam, 1930s

The first well-known home treatment team that is directly linked to the development of home
treatment in the UK emerged during the Great Depression in Amsterdam. At the time, Arie
Querido, a young psychiatrist inspired by Adolf Meyer’s ideas about psychiatry, was invited
to take a position on the Public Health Board of Amsterdam (Boenink & Huyse, 1997). Due
to the economic constraints of the great depression, the board charged him with reviewing all

59
admissions and discharges from Amsterdam’s mental hospitals with an eye towards limiting
the expenditure of public funds (Lemkau & Crocetti, 1961). To limit the use of funds for new
patients, he began treating those who requested admission to a mental hospital in their homes,
and in effect, pioneered the HTT (Boenink & Huyse, 1997).

The rationale behind the development of this service was primarily an economic one, but it
produced a service similar to today’s HTTs. Like current HTTs, they ran a 24-hour service8
with nurses and psychiatrists responding to calls, and an aftercare programme to ensure
integration into the community post hospital stay (Lemkau & Crocetti, 1961; Millar &
Henderson, 1956). Querido stated that the purpose of his service was “to erect a buffer
between society and the patient”, to allow them to function within society and not, in the case
of asylum treatment, apart from it (Lemkau & Crocetti, 1961:782). To facilitate this, a second
part of the service was created to find these individuals housing and a steady job. The impact
of finding employment and housing for patients as well as treatment, constituted “direct
manipulation of the patients’ social environment in order to minimise the consequences of the
illness” (Lemkau & Crocetti, 1961:783). As the service evolved, Querido directed it to
intervene on the determinants of mental health in addition to the illness itself, conceptualising
the patient within an environment that had a distinct effect on the illness.

Querido’s service was not isolated, and word spread across the world. Amsterdam became a
model for the development of services as far away as Boston in the US (Friedman et al., 1964),
Nottingham (Macmillan, 1956) and Worthing (Carse et al., 1958) in the UK, and Samsø in
Denmark (Nielsen et al., 1965). The spread of this service model was, in part, thanks to
Querido’s hospitality in welcoming visitors willing to learn from his approach, including an
American sociologist and a psychologist (Lemkau & Crocetti, 1961), at least one British
psychiatrist (Spingarn, 1959), and two Scottish psychiatrists. These visitors in turn were
inspired in most cases to create their own services (Millar & Henderson, 1956). It is to the
British services that I now turn.

8
Querido referred to his team as a Psychiatric First-Aid Service

60
British Creativity: Worthing and Nottingham 1946 - 1968
In 1948, the National Health Service (NHS) officially came into existence. During the process
of establishing the NHS, all hospitals and mental hospitals were nationalised and the NHS
divided its services into three separate streams: hospitals, general practitioners, and local
health authority services (Freeman, 1998). Once the NHS was established, it experienced
three distinct shocks which coloured their policies going forward (Klein, 2010). The first shock
was a gap between the resources that had been assumed to be necessary to setup and operate
the NHS and the actual amount needed, which was much greater. This led to fiscally tight
times and rationing of resources. The second shock was the actual administering of a new
service, which placed stress on “achieving organisational stability” over innovation (Klein,
2010). The emphasis on achieving stability led to low visibility and prestige for the office of
the Minister of Health. This lack of prestige led to a parade of ministers; six different ministers
presided over the NHS between 1951 and 1958. With a struggle to achieve stability, came a
move away from collectivist planning towards a minimalist policy that allowed for the
creativity at the periphery of ministerial control, but shied away from national plans (Klein,
2010). Klein writes that at the time, “there [was] no initial revelation from an all-wise centre,
but a gradual process of professional consensus building” (2010:33). This resulted in a policy
which allowed the local authorities and services to govern themselves, giving them freedom to
address how patients were treated locally, which resulted in a blossoming of creativity (Klein,
2010).

It was during this time of post-war austerity and creativity that the mental health services in
Worthing and Nottingham were created. The Nottingham service, developed by Duncan
Macmillan, took a public health approach to mental illness while Joshua Carse, with the
support of the Medical Research Council Clinical Psychiatry Unit at Graylingwell Hospital
and the local community in Worthing, was concerned with reducing rising admissions to
hospitals by using a home treatment service (Carse et al., 1958; Macmillan, 1956; 1958; 1960;
1963; 1971; Spingarn, 1959). The service in Nottingham began shortly before the creation of
the NHS and was the brainchild of Duncan Macmillan (1958), an innovative and forward-

61
thinking psychiatrist. Macmillan began by lobbying the City of Nottingham to create a new
position: the Medical Officer of Mental Health. The city created this role in 1946 and named
Duncan Macmillan as the first Medical Officer of Mental Health for the City of Nottingham.
This position gave Macmillan (1958) control of Mapperley Hospital (the local asylum) and
responsibility for the mental health of the city itself. Macmillan (1958) described his role as
that of a public health administrator, which made him responsible for all mental illness in the
city, the provision of treatment, and educating the public, as well as taking preventative
measures. With the creation of the NHS, the Minister of Health was required to approve
several changes to the administration of mental health care in Nottingham, and Macmillan
devised a scheme based on a policy of “short term admission to the hospital with long-term
care of patients carried out on a domiciliary and outpatient basis” (1958:5). Thus, Macmillan
created the first British home treatment service,9 as well as one of the first public health
approaches to mental health.

The Worthing Experiment began in 1955, when a small group of psychiatric researchers (Carse
included) traveled to the Netherlands to visit Querido (Spingarn, 1959). Upon their return,
they sought funding from the Nuffield Provincial Hospitals Trust and support from the
Regional Hospital Board to put together a service in Worthing that would be run out of
Graylingwell Hospital in Chichester (Carse et al., 1958). Graylingwell was unique among
traditional Victorian asylums as it was located quite close to the centre of town. At the time, it
was also home to the Medical Research Council, Clinical Psychiatry Research Unit created
by Carse10 and later run by Peter Sainsbury (1971). Together Sainsbury and Carse were
responsible for a community treatment programme, including domiciliary care or home
treatment, that lasted from 1957 until at least 1968. The service began at “The Acre” in the
seaside town of Worthing, later expanding into Chichester and nearby rural areas (Grad &
Sainsbury, 1963; 1968; Morrissey & Sainsburg, 1959; 1971; Spingarn, 1959).

9
The Nottingham home treatment service was referred to as Domiciliary Care.
10
Carse created the Clinical Research Department in 1947 that would later become the MRC research unit ten
years later.

62
This programme was considered successful in reducing admissions to the hospital and was
heralded across England with articles in daily newspapers in Manchester (1958), Nottingham
(1958), London (1958), and Liverpool (1958), among others11. The experiment itself was
documented by the BBC in a special called “The Acre”, which was well received by the
public. The reason that more was not done to make this service a reality across the UK at the
time was perhaps due to the parade of health ministers, a lack of central authority in the NHS,
a conservative psychiatric establishment, and the practice of allowing local control over
services (Anderson, 1965; Parnell & Skottowe, 1958). There were other domiciliary care or
home treatment teams that were modeled after the Worthing Experiment but none survived
for long (Leyberg, 1959; May, 1961). Whatever the reason, home treatment did not appear
again in the UK until the 1980s, and instead, the historical development continued in
America.

US Home Treatment, 1950s and 1960s

American services were heavily influenced by the British, but took a slightly different
approach in the 1970s and 1980s. Although there were several service models to choose from,
such as Boston (Friedman et al., 1964), Kansas (Burnham, 2006), and Kentucky (Pasamanick
et al., 1964), the most influential was Kentucky as it made national news at the time (Harrison,
1964). Benjamin Pasamanick’s home treatment programme for “schizophrenics” was modeled
on a home care plan for tuberculosis. He felt that “schizophrenia had many similarities, both
medical and social, to tuberculosis, and might therefore be treated in a comparable manner”
(Scarpitti et al., 1965:90). This was a departure from other services; by comparing
schizophrenia with tuberculosis, the researchers were implicitly and explicitly constructing a
picture of patients as subject to social squalor, and generally part of a less desirable social class.
This comparison also made implicit reference to the slow “consumption” of the patient by an
illness, which can only be held at bay by the provision of medical treatment. As this team was
based on a public health approach to tuberculosis, Pasamanick employed public health nurses
instead of mental health personnel to treat these patients in their own homes.

11
Courtesy of the West Sussex Record Office.

63
The programme was setup with nurses carrying out home visits and psychiatrists working from
an office. Nurses helped to collect information on the patient as well as data on how patients
were doing in the programme that was then reported to the psychiatrists. The nurses provided
medical support and also gave assistance with other physical illnesses, economic trouble, and
problems with family relationships (Scarpitti et al. 1965). The nurses often found it difficult to
help their patients due to their inability to change the conditions in which they lived, as well as
the troubled social relationships by which they were surrounded (Scarpitti et al., 1965). At the
end of the programme, the public health nurses advocated for “an enriched program, including
homemaking services, occupational guidance and training, sheltered workshops, family
counseling, training in child care, and help in other everyday activities” (Scarpitti et al.,
1965:95). That is, the nurses suggested training patients, and the psychiatrists in the
programme agreed that a failure to intervene on these issues would keep patients from
functioning in the community (Pasamanick et al., 1964). This focus on training would be
expanded on by the team in Madison in the 1970s.

Training in Community Living, 1970s

The 1970s ushered in a new era with the rise of a particular neoliberal type of governance.
Over the next three decades, the social and political milieu moved away from the social
solidarity of the welfare state, fostering instead a view of the individual as a self-interested,
responsible consumer, capable en masse of directing market forces through perceived
individual choice. This change in the political and social milieu was met with a corresponding
change in the psychiatric establishment and an evolution in home treatment. In 1972, Leonard
Stein and Mary Ann Test began the Training in Community Living (TCL) programme, a
community-based programme similar to what was envisioned by Pasamanik and the public
health nurses (Stein & Test, 1980; Test & Stein, 1980; Weisbrod et al., 1980). The
programme was designed to replace hospital treatment and was created as a direct response to
“a sizeable percentage of the emotionally disturbed [who] continued to spend considerable
time in mental institutions, to function poorly between admissions, and to experience high
readmission rates” (Stein & Test, 1985:10). These were not self-interested and responsible

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consumers/patients; rather they were suffering not just from mental disorders, but from three
“disabling characteristics”:

A limited repertoire of instrumental and problem solving behaviours to meet the

goals and demands of life, which leads to persistent difficulties with work habits,
socialization, leisure time activities, and so forth; powerful dependency needs,
often expressed as aggressive dependence on family or institutions; and a
capacity to develop severe psychiatric symptomatology when confronted with
mild to moderate degrees of stress (Stein & Test, 1985:10).

These “disabling characteristics” on the part of the patient were not specific to any particular
diagnosis; rather they were believed to “cut across diagnostic categories” (Stein & Test,
1985:10). The goal in identifying these characteristics was to intervene in them, and in doing
so, extend the tenure of patients in the community. This was a shift in focus from treating the
illness to training the patient to live with their illness in the community. This repositioned the
role of the patient from passive recipient of care in the home to actively responsible for staying
well and out of the hospital. The training was based around providing the patient with a set of
skills directed at creating self-sufficiency, ranging from grocery shopping and dietary needs to
using public transit and even learning vocational skills. They also provided early forms of
psycho-education, such as “educating patients about symptoms and their interaction with
stressors and development of strategies to minimise and manage the symptoms” (Test et al.,
1985:18).

The need for training to foster self-sufficiency suggests that these patients were viewed by the
team as “pathologically dependant” on institutions and family members, with little to no
motivation to engage with life and little ability to sustain the activities necessary to be self-
sufficient (Stein & Test, 1985). To evaluate this service, a poor outcome was considered as
any increase in the use of hospital-based services after the experimental programme was
withdrawn (Stein & Test, 1980). A positive outcome for the patient centred around the
service’s ability to instill a “motivation to persevere and remain involved with life” (Stein &
Test, 1980:393). The values underpinning all of these interventions were four-fold and
outlined by Stein and Test as follows: “(1) it is better to be outside a hospital rather than

65
inside; (2) it is better to work productively than to be dependent on others; (3) it is important
to be effectively interdependent; and (4) it is a good thing for people to be happy” (1980:396).
These values represented an ideal TCL patient who was seen as responsible, with little
reliance on the state or hospital, was employed, and was a good consumer.

The community was considered the ideal place to teach patients to function better, as it was
where those learned skills would be put to use. Living in the community was theorised to
encourage “appropriate behaviour”, whereas the hospital was seen as giving “patients implicit
license to behave in sick ways” (Test et al., 1985:11). Regular people living in the community
were viewed as positive role models for patients by displaying appropriate behaviour. The
patient was responsible for their illness and their display of that illness, and while TCL singled
out the community as the place to learn, it also signaled that it was not a place in which
patients could fit until they stopped (re)producing sick behaviour. The emphasis was on
reshaping the patient to fit the environment and creating a model consumer, rather than
working with the patient’s environment, as one might do in an approach that favours social
determinants.

The way Stein and Test saw the patient and the ideology that surrounded their treatment
programme was not being overstated here or given undue scrutiny. As the authors said
themselves, “the most important impact of the TCL model is the effect of its principles and
philosophy of treatment on views of how to care for persons with persistent, long-term mental
health problems” (Stein & Test, 1985:14). They went on to note in the same passage that
these principles have “widespread application” (Stein & Test, 1985:14). The TCL method
would go on to form the basis for two services provided today; home treatment and assertive
community treatment. The results of the TCL study were so encouraging that it prompted
replications around the world, which eventually led back to the UK.

66
The Return of Home Treatment to Britain and the TCL Replications
The seeds of the return of home treatment to England12 were planted in the 1960s when
Maxwell Jones, a Scottish psychiatrist and pioneer in the therapeutic communities movement,
trained and inspired two psychiatrists, John Hoult and Paul Polak. Hoult and Polak both spent
time in Dingleton, Scotland where Jones ran a mental health service and hospital which
included some home treatment (Briggs, 2002:53; Pullen, 1993). Polak would go on to run a
home treatment team and community mental health service in Colorado during the 1970s,
where he would publish several influential papers with Maxwell Jones who had joined him on
the staff (M. Jones & Polak, 1968; P. Polak & Jones, 1973; P. R. Polak & Kirby, 1976)13.
Hoult made the far greater contribution to home treatment, beginning by replicating TCL in
Sydney, Australia (Hoult & Reynolds, 1983; Hoult et al., 1983) and later playing a key role in
the resurgence of home treatment in the 80s and 90s (Hoult, 1986; Johnson, Nolan et al.,
2005; Minghella, Ford et al., 1998).

The TCL model had great success, as it was also replicated in Michigan, Washington,
Birmingham, UK, and London, UK (Dean & Gadd, 1989; 1990; M. Muijen et al., 1992; Stein
& Test, 1985). The UK Department of Health helped to fund the creation of the Birmingham
and London services, which would slightly modify the TCL programme. These slight
modifications were endemic of a larger shift in successive replications that lost touch with the
original focus on training and values, and yet, continued to focus on the promising potential
economic implications of wide-spread use of home treatment.

The Birmingham team, despite calling themselves a TCL replication, did not appear to follow
the philosophies laid out by the TCL study, nor did they mention any type of teaching or
training provided to the patients. Instead, it appeared that they relied heavily on the extended
families of their patients to act as support systems (Dean & Gadd, 1990). In terms of their

12
One HTT type service existed apart from this model. See Scott, D. and Starr, I. (1981). A 24‐hour family
orientated psychiatric and crisis service. Journal of Family Therapy 3(2): 177-186.
13
Polak would later publish influential articles on home treatment in 2003 which I found pinned to the bulletin
board of the HTT I studied (Bridgett and Polak, a2003; b2003).

67
argument for home treatment, they focused on feasibility and the ability to reduce costs, as
well as reduce demand for inpatient beds. The Southwark team on the other hand did make
an effort to adhere to the TCL programme, trying their best to deliver on the “training in
living” component of TCL.

The Southwark team reported using a modified TCL model. They introduced their work by
comparing it to similar programmes of care for diabetics and rheumatoid arthritis, which
required “a daily living support network to deal with the crises and give ongoing aid
throughout illnesses” (I. Marks, Connolly and Muijen 1988:23). Their intention was to
circumvent the failure of patients to live in the community by teaching them an individually
tailored set of general skills at the site (the home) in which they would be used (I. Marks et al.,
1988). However, they reported a low rate of success with delivering training (M. Muijen et al.,
1992:304). As with the Birmingham study, a significant argument for cost effectiveness was
put forth by the Southwark team, although it was presented in a more nuanced way.

The Southwark team took a system-wide approach to presenting home treatment as cost
effective. They argued that, “despite some continuing deficits, [the patients] became able to
function in the community and cope with occasional stresses while consuming fewer health
care resources” (I. Marks et al., 1988:22). Thus, the fewer resources patients use, the lower the
cost to the entire system, with an added bonus of slight reductions in the cost of treatment.
The underlying logic to their argument was that outcomes for patients were better, though not
by an exceptional margin, and it saved money and resources. But they were cautious about the
possibility of too much focus being put on community care, fearing that it would diminish the
treatment that some patients received in the hospital (Muijen et al., 1992). They stressed that
with the advent of community care, it was necessary to explore and define the role of the
acute ward in order to be able to bring it into the fold of community care.

The Southwark and the Birmingham teams both moved away from the core of the TCL
method and in doing so contributed to a decline in fidelity to TCL among the British home
treatment teams. A second TCL-type home treatment team was set up in Yardley,

68
Birmingham with the help of John Hoult and funding from the Sainsbury Centre for Mental
Health. This team was designed to be part of a robust study supporting home treatment based
on the TCL model. This team produced a study entitled Open All Hours which proved to have
a great deal of influence on government policy (Glover & Johnson, 2008; Minghella et al.,
1998). Although this study and team were influenced by the TCL model, they continued the
drift away from the core values and philosophy. As I mentioned elsewhere, this study, like the
others, put forth a robust economic argument for home treatment. Open All Hours was also the
title of a TV show based around a miserly protagonist who tried to make as much money as he
could while spending as little as possible in the process. In the return of home treatment to
England, the focus on values and training for patients that was held as critical for the TCL
method’s success was slowly relegated to the background as the economic logic behind the
service model moved into the foreground. The economic logic combined with arguments
about patient experience and other factors helped to move the government to develop a
programme of national home treatment (Smyth & Hoult, 2000). Before I examine the
government’s development of national home treatment, it is necessary to look at the
conditions that led to this move.

National Home Treatment

The late 1990s saw the rise of a new Labour Government under Prime Minister Tony Blair,
and a renewed emphasis on improving the NHS and addressing its perceived weaknesses.
With the rise of Tony Blair’s reinvigorated “New Labour” came a focus on the “Third Way”,
an ideology that mixed free market ideals, social justice, and a rhetoric that advanced the
notion that rights come with responsibilities (Klein, 2010). The Blair government began to
change the NHS in a way that created targets and budgets, exerting control from the centre
but allowing the periphery freedom to meet these responsibilities. As Klein put it, this led to
“national standards but local freedom to manage and innovate” (2010:190). In other words,
national programmes were instituted that demanded certain services or targets, but allowed for
a modicum of flexibility in their implementation and management. These national standards
were harnessed to address issues perceived from the inside and outside of the mental health
system in the UK.

69
On the inside, mounting evidence revealed a mental health system in crisis. Yet, it was hard to
distinguish just how bad the crisis was due to the delay in the release of statistics by the NHS
(Appleby, 2003). Despite this, there were some critical articles that attacked the therapeutic
nature of part of the mental health system. Matt Muijen (1999), a collaborator on the
Southwark service and then Director of the Sainsbury Centre, painted a dire picture of
inpatient services in a 1999 editorial published by The British Journal of Psychiatry. Muijen
considered that the main problem with the mental health system was to be found at its very
heart, namely the acute ward. Acute wards were often running with occupancy rates above
capacity due to a lack of beds. When these services began operating above capacity, they
were filled with only the most disturbed patients who needed urgent care. Adding to this,
Muijen argued that there were low levels of nursing staff and a patchwork of therapeutic,
social, and recreational activities that led to “an atherapeutic environment” and a “care
vacuum” rather than a frontline treatment facility for the most vulnerable (1999:257). In
summary, Muijen argued that “a picture is emerging of an inefficient, atheraputic and poorly
coordinated service, profoundly demoralizing to both patients and staff and unable to cope
with the growing pressures” (1999:258). He ended his editorial by highlighting the importance
of focusing on the whole system as well as the interactions between its parts and for new
alternatives to admission, including home treatment and early intervention.

In 2003, Louis Appleby (2003), the National Director for Mental Health, reflected on the
crisis in an editorial for The Psychiatric Bulletin. He warned that the crisis in acute care
experienced in the 90s had not resolved and appeared to be continuing well into the present.
It was apparent that by the end of the 90s, there was a climate for change inside the wards
that was matched by a burgeoning public outcry outside of the wards. This outcry was based
on media coverage of multiple reports of mentally ill individuals who committed homicides,
coverage which severely overstated the prominence of such acts (P. Bartlett, 2000; Taylor &
Gunn, 1999). The outcry quickly became an uproar, so much so that Frank Dobson, the
Secretary of State for Health, declared in a newspaper interview that “care in the community
has failed”, following reports of at least one homicide due to a failure in the mental health

70
services (BBC, 1998; Peck, 1999). The acute care crisis and public uproar proved sufficient to
move the government towards intervention.

Spurred to action, the government formulated and implemented a plan to modernise the NHS
and its mental health services, injecting a substantial amount of funding to facilitate this. For
the first time in NHS history, this intervention was driven by the centre of the bureaucracy
imposing new systems, services, and targets on the periphery (Klein, 2010). This was to be a
whole system change and the resulting action and “modernisation” produced the first National
Service Framework (NSF) for NHS mental health services. The NSF contained only a small
section on national home treatment and made reference to the Open All Hours study while
outlining its goals for the policy (Department of Health, 1999). Without knowing it, the
government was setting the grounds for a further drift away from the core tenets of TCL, a
drift that, combined with a lack of a detailed guidance on implementation and operation from
the government, would result in services with practices that were very flexible. With such
strong arguments put forward for HTTs’ ability to save money and beds, it created a situation
where they could be used to cope with or manage austerity.

Home Treatment in Flux

At this point in history, as the adherence to TCL seems to be dropping off, the second step in
linking home treatment to austerity arises. For home treatment to ultimately become a service
that is used to manage austerity, its practice must be flexible. Without a specified pattern of
practice being required, HTTs are open to being manipulated towards managing financial
expenditure. How then did the practice of home treatment become so flexible and undefined?
I will show below that the government failed to provide detailed advice on how to operate
these teams. This failure ultimately led to a debate between prominent psychiatrists on
whether home treatment did or did not save money and beds, which became the central
discourse around these teams, further enshrining an economic logic around their use.

When the government created the NSF for Mental Health, they also created a companion
Policy Implementation Guide (PIG), which laid out how NSF was to be implemented

71
(Department of Health, 2001). In the PIG, the government failed to provide a clear guide to
home treatment practice or reference to where such a guide could be found. The guide failed
to mention the TCL model and instead referred to the Birmingham teams and the Southwark
study, none of which had detailed explanations of practice or mentioned the values and
training that were considered keys to success by the TCL researchers. In doing so, the PIG
set the table for a very loose and flexible conception of what a home treatment team ought to
do, leaving it to Non-government organisations (NGOs) to try and organise training for
individuals setting up the over 300 teams across the country.

The Sainsbury Centre for Mental Health, an NGO which at the time was led by the home
treatment veteran, Matt Muijen, and was also responsible for the Open All Hours study, created
one of the only how-to guides for home treatment (M. Muijen et al., 1992; Sainsbury Centre
for Mental Health, 2001; Woodbridge, 2006). The Sainsbury Centre’s guide for home
treatment focused on some of the forgotten aspects of the TCL model, including training and
working with the patient rather than on the patient. In the rush to establish HTTs across the
UK, despite the intervention of the Sainsbury Centre, the focus on activities of daily living
and other social interventions appears to have been lost in many of the teams. A 2006 survey
of HTTs revealed that most home treatment teams’ activities were focused on medication.
Indeed, it was highlighted that only “around a third to a half of teams provided other key
interventions around once a week or more frequently, such as therapeutic work or practical
help for family members, help with housing, income, activities of daily living or expanding
social networks” (Onyett et al., 2006:5). A more recent survey in 2018 showed that out of 181
teams, 41% grocery shop with their service users, 19% prepare food for/with, 12% help clean,
59% help with benefits, and 52% help with debt (Lloyd-Evans et al., 2017)14. These surveys
bring to the fore the fact that many of the original tenets of the TCL programme have been
lost and that much of the focus on home visits is medication based. From the very beginning
of national home treatment in the UK, there has been an argument about whether it is a useful
service that achieves what its proponents claim (that it saves beds and money). The lack of a

14
The team I was with did all of these things, though some were not done on a regular basis.

72
standard practice, wide variation between teams, and small base of evidence helped to open a
rift between psychiatrists who supported home treatment and those who argued it was an
unnecessary waste of resources (Deahl & Turner, 1997; Pelosi & Jackson, 2000).

It is necessary to look at this rift as it became central to home treatments’ further development
in the UK after 2001. John Hoult and Marcellino Smyth (2000) began the defense of home
treatment just before the PIG was released in an article called The Home Treatment Enigma. The
article is both a response to critics of home treatment (Deahl & Turner, 1997; Pelosi &
Jackson, 2000) and an introduction to home treatment for the uninformed. Specifically, the
authors responded to claims that the Department of Health was reducing beds based on an
erroneous assumption that home treatment could keep people out of the hospital, and that
HTTs cost more and lacked a substantial evidence base (Deahl & Turner, 1997). These points
became a core complaint from future detractors (Tyrer, 2011; 2013b; Tyrer et al., 2010). Hoult
and Smyth argued that they never claimed inpatient beds would become unnecessary. They
instead pointed out that patients wanted these services, the services were no more expensive
than others, and they provided the same or better outcomes than the hospital (Smyth &
Hoult, 2000). They expanded on this further by arguing that “higher patient satisfaction
should not be dismissed as a soft finding” and “avoiding admission to hospital provides a
critical opportunity to alter for the better the personal set of meanings surrounding mental
illness and to impact on the trajectory and personal narrative of the psychiatric patients
experience of his or her illness” (Smyth and Hoult, 2000:306). Their approach valued patient
experience in mental health service, but still sought to confirm that home treatment was meant
to help avoid admissions and this was a good thing. In effect, Smyth and Hoult were arguing
that their detractors did not care as much about patient experience as they did about other
things like evidence and cost effectiveness. Yet, Smyth and Hoult, having referred to the issue
of patient experience, focused the majority of their argument on the reduction of beds and
other economic issues. Both parties seemed to lose the central point of patient experience.
Instead the argument around home treatment as a service became one around the economic
benefits of home treatment which supported the trend I have shown in the history of home

73
treatment, a trend that increasingly values the economic aspects of home treatment over other
aspects, to the detriment of the development of the service.

The debate over home treatment only got more intense as the national policy was established,
and the economic logic of home treatment became the central focus of arguments for and
against home treatment. Two psychiatrists emerged as the leaders of this debate. The first was
Sonia Johnson, a psychiatrist at UCL, who produced a study in North Islington showing a
clear reduction in admissions because of the impact of the HTT (Johnson et al., 2005). This
study has since become the centrepiece in the argument that further bed reductions would not
be harmful and that home treatment teams can reduce admissions. The second psychiatrist and
former editor of the British Journal of Psychiatry, Peter Tyrer (2013a), emerged on the side of
increasing acute beds and dropping home treatment in favour of CMHTs. Tyrer entered the
debate through a study he and others had published, casting doubt on the ability of HTTs to
lower the number of admissions and raising concerns about the number of suicides (Tyrer et
al., 2010). However, their article was contested by two different psychiatrists who submitted
e-letters to the journal arguing that the authors’ methodology was flawed and that it was
important “[not to] throw the baby out with the bathwater” (Tyrer et al., 2010). A later article
was published supporting Johnson’s findings and criticising Tyrer (Barker et al., 2011) with
other commentators voicing concerns over the article (Bhattacharya & McQueen, 2011).

The debate ultimately produced a reply from Johnson (a rebuttal from Tyrer is examined
below) that claimed that, due to the lack of specific guidelines and the variability already
present within HTTs, not all teams were reducing admissions. In short, some teams just were
not doing it right. This argument suggested that there was (a) a right way to do home
treatment and (b) that it was not clear to many teams what the right way was. This has come
to be known as the fidelity argument, which led to Johnson and others embarking on a large-
scale study to produce a fidelity scale and a set model for home treatment (Johnson, 2013;
Lloyd-Evans et al., 2016). The hope was that this model could put to rest the arguments
against home treatment. The reality of the situation was that no one seemed to be entirely
sure what exactly home treatment was or what it could do, as evidenced by a need for a

74
fidelity scale. Arguments for and against home treatment were also featured in a Maudsley
Debate between Tyrer (2011) and Johnson (2011), who outlined their respective arguments in
an issue of the British Medical Journal.

Peter Tyrer published multiple papers that criticised the introduction of home treatment, most
of which came after the Maudsley debate between Tyrer and Johnson. He believed that most
of the reductions in admissions had already been accomplished by community mental health
teams and that home treatment was incapable of further reductions (Tyrer, 2013b). He argued
that the NHS needed to return to CMHTs and stop using home treatment in the pursuit of
what he called a “virtual bedless psychiatry”(Tyrer, 2013b). In the government’s defence, the
PIG did not mention that a reduction in admissions was part of what home treatment should
do, although the overall indicators for outcomes in the NSF were directed towards reducing a
need for beds (Department of Health, 1999; 2001). Tyrer also argued that the early goals of
community psychiatry were still to be lauded, but that the government had hijacked this
policy “with the word ‘cheaper’ being substituted for ‘better’”(2013b:36). In another recent
paper, Tyrer summed up his viewpoint quite clearly and it is worth quoting at length:

The early gloss has gone off the excitement of community psychiatry and the
focus has been more on excluding people from hospital than providing good
community care. The general mantra of ‘community psychiatry good, hospital
psychiatry bad’ has been a two-edged sword, for although it has promoted the
development of many community psychiatric services, it has also led to the
neglect of the proper function of in-patient care, a combination of asylum and
rehabilitation, and today may have reached a point where a fundamental wish
to improve patients’ autonomy is being removed by an over bureaucratised
system of community care that is obsessed by risk, and in danger of promoting
greater institutionalisation by a complex regulatory framework that denies the
flexibility that is essential to good community psychiatric practice. (2013a:336)

Tyrer’s argument is not completely without merit, as there are still major problems in the
mental health care system. That being said, Johnson had an argument that has merit because
the evidence from surveys shows so much variation (Lloyd-Evans et al., 2017; Onyett et al.,
2006). The evidence and history of home treatment can be read in different ways, but two
points can be agreed upon so far: (1) that HTTs have a variable practice that stems from the
75
way that they were developed and introduced; and (2) there is an economic logic that slowly
moves from an added bonus of HTTs, to a (perhaps the) defining feature.

The dialogue and debate about HTTs have taken on a format of community care versus
hospital treatment. This dichotomy inserts an artificial divide into a system that is not, nor
should be, divided. The general thrust of the PIG and NSF was a whole system change, for
better or worse, because the system was inextricably linked. These teams continue to remain
ill-defined in such a way that allows them to be defined by many of the services and
conditions around them. This is even more prominent with mental health trusts redesigning
the way that HTTs operate to suit the (often financial) needs of the trust (Gilburt, 2015). I will
explore this later in the dissertation, however it is worth establishing the conditions around
home treatment in the following section as they comprise the third step in linking home
treatment to austerity.

Austerity in Mental Health Services

“The relationship between funding in mental health and quality of care is not a simple one”

-Helen Gilburt (2015:20)

At this point I have established that there is an economic logic that develops and evolves
alongside home treatment, which eventually supersedes other important aspects of practice.
By way of government decisions to not provide strict guidelines and a slow drift from the core
tenets of past successful methods of home treatment, HTTs are left with a flexible practice.
This flexibility and this uncertain practice leave them open to being used to mitigate the
effects of austerity on the mental health trust, individual or both. In the next section, I will
look at the effects of austerity policies on mental health trusts, and their “trickle down” effect
on HTTs.

Absolute funding for mental health trusts has fallen from 2008-2012 and again in real terms
from 2012-2017, although it is hard to determine the exact cuts and effects on services

76
(Bulman, 2018; Gilburt, 2015). Psychiatric beds numbers can be used as a barometer for cuts:
from 1998 to 2012 bed levels plummeted by 39%, and from 2011 to 2013 the government
oversaw the closure of 1,700 acute care beds (Gilburt, 2015; McNicoll, 2013). This drastic
paring down of beds has left NHS trusts in a precarious position, with many acute wards
running up to 138% capacity (The Commission on Acute Adult Psychiatric Care, 2015).
Home treatment teams are used to counteract these effects and are often the reason why
wards can run above capacity in the first place. Patients on Section 17 leave15 with home
treatment technically are still ward patients and the ward must be ready to readmit the patient
if they become unsuitable for home treatment, but beds are rarely held open due to the lack of
capacity. The demand for beds in acute wards can become so great that there are moments
where there are no adult beds in all of England (Siddique & Meikle, 2015). Trusts have
responded to excess demand by placing patients in temporary private beds outside of their
catchment area, costing them millions of pounds (Bloom, 2015). The Royal College of
Psychiatrists has stated that the lack of beds is “pushing the mental health system to a
breaking point” (Siddique & Meikle, 2015).

Despite the evidence of a crisis, the government has continued to cut funds to mental health
services (Bulman, 2018; Docherty & Thornicroft, 2015:34). Recently, the national tariff, a
standard price paid for NHS services, fell by 1.25% for mental health trusts in 2014-2015 and
around 40% of mental health trusts have had cuts to their income (Gilburt, 2015).
Additionally, specific services in mental health trusts have received cuts to their funding
(beyond inpatient wards), including early intervention services and home treatment services.
To further complicate matters, despite these cuts, just over half or 58% of mental health trusts
still posted a surplus in 2014-2015. How, with all of these cuts, did some mental health trusts
still manage to post a surplus?

15
Section 17 leave is used in cases where a service user is on a Section 2 or 3 and is not allowed outside of the
hospital. Section 17 allows for leave outside the hospital in a predetermined place for a short length of time. It is
often used as a trial period for home treatment where an individual is still technically on section in the ward but is
being treated at home by the HTT. This is covered in detail in the next chapter.

77
To understand how some Trusts are posting surpluses while others are posting deficits, it is
necessary to look at what is called “service redesign”. The King’s Fund has surveyed mental
health trust strategic documents and found that many are restructuring to pursue financial
sustainability, often in anticipation of cuts (Gilburt, 2015). In doing so, they are stepping away
from proven, evidence-based mental health trust design and practices (Gilburt, 2015). This
service redesign is often focused on home treatment, expanding the work they are responsible
for beyond the historical models of treatment, and in some cases merging their functions with
other specialist teams like CMHTs. Information on exactly how trusts are redesigning their
services, the results of their redesigns, and what impact they have on service users is scarce, as
Helen Gilbert points out (2015). This dissertation reveals the efforts of one mental health trust
to redesign services to utilise home treatment as a way of reducing the pressure on beds,
limiting the reliance on private beds, and managing the Trust’s bed stock. A result of this
restructuring for home treatment is the necessity to hold on to and “contain” patients that are
riskier than normal or actively suicidal while they are awaiting a place on a ward—practice
that evidence does not support.

This brings up an inherent problem with redesign and stepping away from standard practices:
what happens if things don’t go as planned? The King’s Fund report has pointed out that
“although [service redesign] plans commonly refer to risks associated with poor
implementation, few factor in the risk that the plan itself may not deliver, or may have
unforeseen consequences that will have a negative impact on the desired outcomes” (Gilburt,
2015:18). Already, some of these unforeseen consequences are appearing within home
treatment; England has shown three times as many suicides by patients under the care of an
HTT versus those under inpatient care (Hunt et al., 2016; Hunt et al., 2014; National
Confidential Inquiry into Suicide and Homicide by People with Mental Illness, 2015).

So what other impacts are these redesigns having on care? Thus far, the Care Quality
Commission has found that the experience of care is highly variable and dependant on the
postcode of the patient (2015a). Having said that, The King’s Fund report is highly critical of
the lack of information necessary to determine the quality of care, stating that “in many areas

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of care there is no information at all, in others information is incomplete, of poor quality or
unlikely to be representative of the true picture” (Gilburt, 2015:19). As such, there is an
evolving situation that produces highly variable care with no effective way of evaluating that
care. With home treatment already variable in service and being utilised by mental health
trusts in new and risky ways, the inability of the services to produce information about the
quality of care is concerning, especially when faced with pressure from outside the mental
health services.

Austerity, the Welfare State, and its Effect on Mental Health

“Life under austerity is growing increasingly tough for the vast majority of people, and mental
health is one of the casualties of this era”.

-Kate Mattheys (2015:475).

Austerity policies are not just being applied to the health service in the UK; they are also
being applied to many of the services that help support people with mental health issues living
in the community. The fourth step in linking home treatment to austerity involves looking at
how austerity policies have affected services outside of mental health and how this has had a
direct effect on the wellbeing of individuals being treated by mental health services like home
treatment. Austerity in the UK and the rise of the workfare state have interacted in significant
ways that have increased “the overall burden of mental distress and marginalisation”
(Cummins, 2018:1145). For instance, social care support for people with mental health
problems has been significantly affected by reductions in local authority budgets (Docherty &
Thornicroft, 2015). These cuts have resulted in 30,000 people who suffer from mental health
problems losing their social care support, resulting in further stress on mental health services
and a turn towards crisis services, like home treatment and Accident and Emergency wards
(Docherty & Thornicroft, 2015; S. Williams, 2015).

My dissertation will demonstrate that perhaps the biggest impact of austerity measures
(outside of direct cuts to mental health services) on mental health and mental health services

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can be found in the substantial changes to the benefits system. These changes have emerged
out of the UK government’s response to the 2008 global recession and are part of an economic
recovery strategy. In 2008, the government introduced changes to benefits for people with
mental illness with the Employment and Support Allowance (ESA) and the test to determine
eligibility, the Work Capability Assessment (WCA). This was done with the aim of increasing
the number of people who suffer from mental health conditions and other disabilities in work
and resulted in the creation of the Work Related Activities Group (WRAG) within ESA,
which is specifically for people who can do “some work” (Hale, 2014). Evidence is beginning
to show that the introduction of these new rules and practices surrounding benefits have had a
harmful effect on mental health (Barr et al., 2015; Gunnell et al., 2015). A recent study on the
WCA focused on individuals assessed between 2010 and 2013 (Barr et al., 2015). Their
findings indicated an association between use of the assessment and “an additional 590
suicides, 279,000 additional cases of self-reported mental health problems and the prescribing
of an additional 725,000 antidepressant items” (Barr et al., 2015:3). Although it is not entirely
conclusive that the WCA caused these effects, it forms part of an overall trend that suggests
that these new benefits measures have been having an adverse effect on mental health. During
my research, I found that many individuals had difficulty with their benefits that spurred a
crisis in their mental health. These problems often involved the WCA and the move towards
reintegrating the individual into the labour force.

The WRAG was developed with the purpose of moving individuals who suffer from mental
illness and other disabilities into work. This was done through programmes that would
encourage a pathway towards work and sanction individuals who did not engage with the
work pathways. In a survey for the mental health charity, Mind on WRAG, Catherine Hale
found that it was

highly probable that the fear and distress caused by an excessive focus on
conditionality, and the associated threat of sanctions, is linked to the large scale
deterioration in health, wellbeing and confidence reported by respondents.
Survey results suggested that the overall impact of participation in the WRAG
is to move people further away from work, instead of closer to it (2014:6).

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This is part of a wider trend which is not only revealing that the government’s approach to
putting ill people back to work is failing, but also that people who suffer from mental health
conditions are being adversely affected by it. Consequently, home treatment faces increasing
pressure from patients who have been moved to crisis either by their involvement with the
WRAG or by sanctions to their benefits, as a result of disengagement with the WRAG.
These issues can make relatively straightforward home treatment cases more complex,
especially when they involve sanctions as this can result in the loss of a home or substantial
rent arrears.

Benefits sanctions involve stopping benefit payments for a period of time because of a failure
to show up for appointments or a failure to look for work (P. Butler, 2015). Since this practice
began, overall benefits sanctions have slowly fallen, while sanctions on individuals suffering
from mental health problems have risen by 668% (Stone, 2015). Sanctions often occur when
an individual fails to show up at a government Job Centre. Stress related to Job Centre visits
and the way in which patients are treated by the Job Centre has negatively impacted their
recovery. This is backed up by research on the rise of male suicides following the 2008
financial crisis, which has shown, among other things which play a role in suicides such as debt
and austerity, that “the negative impact on their mental health of Job Centre targets” (Gunnell
et al., 2015:2) also played a role in the rise of suicides. Negative experiences at the Job Centre
and rising sanctions are perhaps unsurprising, as documents have come to light that show Job
Centre “staff who fail to instigate or approve enough sanctions are subject to performance
reviews” (P. Butler, 2015:1). It is becoming increasingly clear that austerity policies outside of
the mental health services are having a measurable impact on individuals who suffer from
mental illness and likely increasing the demand and complexity of cases for services like home
treatment.

Discussion: History in Context

Home treatment has its origins in austerity and an economic logic has run parallel to its
development throughout history. It reduces the cost of mental health services by diverting
patients who would regularly be treated in inpatient facilities, reducing the use of beds,

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relocating treatment to the home thereby saving costs on operating without a substantial
physical presence (e.g., inpatient ward), and, where possible, affecting change in patients’ lives
to keep them well for longer periods of time, providing cost savings across time. All of these
“benefits” remain attached to the idea of home treatment despite the weak evidence available
to support them.

The actual practice of home treatment is in flux; the origins of home treatment have been left
behind, and the debate about what home treatment can actually do is so thin on evidence that
either side can reasonably argue their point. The argument that a fault in some HTTs’ practice
is keeping them from reducing admissions seems to address the effort to find a method that
supports the economic logic, rather than a concern for the method that represents best
practice. The lack of definition to home treatment practices has produced a situation where
other services that surround home treatment can modify and sometimes dictate the practice of
home treatment. If the inpatient ward does not have the space for patients who are in crisis,
they are then diverted to the HTT or, alternatively, patients who might not be well enough to
leave the hospital are discharged to home treatment to provide the extra capacity needed on
the ward. This is part of the way that an economic logic leads to a redefinition of home
treatment as a method to manage low levels of resources.

This paves the way for mental health trusts who are working to stave off the effects of cuts to
their funding to utilise home treatment in new and creative ways, rendering any attempt to
standardise home treatment contingent on Trust approval (Gilburt, 2015). Although there are
attempts by researchers to standardise HTTs, their efforts will ultimately have to compete
with the need of mental health trusts, just as HTTs have to consistently (re)define their
practice to adjust to this environment. The increasing pressure from austerity measures outside
of mental health are having an effect inside the mental health system, increasing the demand
for services and creating more mental distress (Barr et al., 2015; Gunnell et al., 2015).

Benefits sanctions, social care cuts, and local authority cuts create long standing issues (e.g.,
housing, social care, sanctions, and unstable/temporary work) that cannot be addressed by

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HTTs without a return to the neglected elements of training in everyday living in home
treatment. Other services like CMHTs now rarely have the ability to make an impact on
issues—like housing, social isolation, or helping a service user avoid sanctions—as they lack
the resources and time to address them. The startling lack of data around these issues is both
adding to the ability of mental health trusts to make changes without an evidence base and
also decreasing the visibility of the effects of these changes on patient experience. Quality of
care is taking a backseat to the concerns of operating a service under a particular budget or
with a particular financial goal in mind. It is perhaps best to return to what an early HTT in
Bolton, UK reported in the late 1950s; although saving beds is great, and is what home
treatment and community care does, “it is another thing to plan a service with this as its
primary aim because this engenders serious risk and hardship for both the patient and their
families” (Leyberg, 1959:283). Serious risk and hardship are already apparent within the
mental health system that is under strain from both the inside and outside. By unraveling what
service redesign means and how austerity and related policies have affected the practice and
experience of home treatment, I can begin to add to add a small piece of the missing evidence.
The first step in illuminating this process is to take a closer look at the practice of home
treatment.

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Chapter 4: Home Treatment Practice

The HTT is part of a pipeline between the inpatient hospital wards and CMHTs. For some
patients, it takes the place of the ward to intensively treat an acute crisis; for others, it
provides a transition from the ward, a step down in treatment intensity. This is process-driven
work; people must be admitted, treated, and discharged from the HTT while the team is
under pressure and dealing with a moderate level of risk. To do this, the HTT is organised
around three central concepts: crisis, formulation, and containment. These concepts underpin
how the team goes about working with patients, deciding who to treat, and ensuring their
ability to maintain movement in and out of the team. In this chapter, I will explore these three
concepts, the admission process, and the decision-making processes. In doing so, I will go
through the team’s handover practice, an analysis of the three concepts, the process of
admitting patients to the HTT, and the key forum for decision-making. This will provide a
foundation on which the practice of the team can be understood in the following chapters.

Morning Handover
Every morning as the nurses, social workers, and support workers filtered in, they took their
seats, booted up computers, and chatted about politics, TV shows, or the latest football
scores. A scheduled nurse would take a turn co-ordinating for the shift, covering a variety of
duties including the morning handover. The majority of the team’s processes began and ended
in a handover meeting, which began with each nurse reading out the latest electronic entry,
summarising the last contact the mental health system had with that individual, and finishing
with the activity due that shift. The summary cut the information down to its basic
ingredients. What was their mental state (were they depressed, psychotic, agitated, calm,
euthymic)? What was/were the problem(s)? What was to be done and when did they expect
the team to visit? The following is an excerpt of a summary for morning review of Ninette:

The team last had her in December 2014; Ninette is a young white British
woman and former dancer. She has a number of different diagnoses: bipolar,
schizoaffective, personality disorder. She is currently hearing negative voices

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 telling her to harm herself. She lacks motivation and won’t go outside.
Currently not attending to activities of daily living. She initially declined home
treatment but is now okay with home treatment input. She has a community
support worker. Evening visits and early in the morning between 10 and 11 am.
We will have to swap her back to a different community mental health team
because she has moved to the other side of the borough.

In addition to the entries that the team wrote, other services involved with the care of patients
also wrote notes. These were then posted in chronological order on the “Electronic Patient
Journey System” (EPJS). Consequently, the team tended to have multiple sources of
information on EPJS that provided further detail on a patient. An additional source of
information outside of what can be found on EPJS was the wealth of experience the staff had
on the HTT. Many of the staff had worked in the area for 10, 20, even 30 years or more,
giving them intimate knowledge of the many patients they had seen in other capacities outside
of the HTT. For instance, some members of the team care-coordinated patients, working with
them in assertive community treatment teams, rehab, or various other acute wards or services.
Whether staff knew the patient or not, they tried to read up on their immediate history after
the morning handover.

Morning handover usually ended around 9AM, when the psychiatrists began to trickle in. As
the psychiatrists walked into the handover (if it was still going), they began to allocate each
other to patients they deemed in need of a visit. Visits from psychiatrists were based on
whether the patient had been seen by a doctor, whether the nurses had asked for a doctors’
visit, or in other cases, whether gathering more accurate histories or adjusting medications was
needed. The shift coordinator would try to keep track of where the psychiatrists were going
and what kind of transportation they needed, ensuring that there were enough pool cars for
the nurses’ visits. This was a part of the process of allocation performed by the shift
coordinator.

The allocation of nurses and psychiatrists to patients was the single most stressful task in the
nurses’ schedule and was never straightforward. First, the shift coordinator ascertained who
was on shift. The team’s complement of nurses, support workers, and social workers

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numbered for each shift between four and seven, plus a manager. They paired up two staff for
the joint visits; usually there would be at least one male staff member in the pair. Two female
staff members were not always considered the best choice for some joint visits, especially if the
patient had a known history of violence or abuse towards women. Joint visits were used for a
variety of reasons, some of which were about the safety of staff if the neighbourhood was
“dodgy”, while others revolved around a patient’s history of violence. If there were complaints
made against the team, a joint visit gave them the ability to have a corroborating account if
something happened. An example of this might be that the patient complained that staff were
derogatory or careless in the way they spoke with or treated them. Next, the coordinator
would allocate the pair to joint visits within a particular area of the borough, trying to
maximise visitation time and minimise travel. As the shift coordinator did this, they often had
a spatial awareness as to the difficulties of navigating a borough that was nearly three times as
long as it was wide. The reality was that travel time can only be minimised as much as is
possible, but sometimes staff members would have long travel times between visits, which
resulted in shorter or rushed visits with patients.

Home visits were not the only things that need to be allocated. A typical stay with home
treatment would mean a review of the patient’s care would take place with a member of the
team, the patient, and a member of the team to which they would be discharged. The
meetings revolved around how the patient’s recovery was proceeding. A discharge meeting
was a similar meeting, consisting of: a member of the HTT, the patient, and a member of the
team to which they were being discharged. These discharge meetings were the last contact
the HTT had with a patient. Discharge meetings involved a sizable amount of paper work for
the HTT staff member, as they would have to produce a summary of the treatment received
and the treatment recommended going forward. Both joint reviews and discharge meetings
had to be allocated by the coordinator. These meetings took place at various CMHT bases
across the borough and were negotiated in advance with patients and teams. Occasionally
these meetings would fall at the same time on the same day. Scheduling these meetings and
the paperwork that went with them could add increased amounts of pressure to allocation and
to the work of the team.

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Shift coordinators, when allocating discharge meetings, would ask for staff who had met or
knew the patient ready to be discharged. Unfortunately, it was not always possible to allocate
these discharges to someone who the individual had met before, which meant that an HTT
member had to read up on the patient in the short window between allocation and visits, and
then attend the meeting. This made it difficult for the team member to have a significant
impact on the meeting or highlight potential steps that would need to be taken for the patient
to continue their recovery.

Allocation created pressure for the staff of the HTT and the process of allocation itself often
broke down into chaos. Once allocation was complete, the coordinator would start on their
own work, which often involved numerous phone calls, chasing down care coordinators of
service users to set up joint review or discharge meetings, or even team-based contacts.
Making things even more difficult and pressured was the occasional crisis that a shift
coordinator would have to manage. If a patient needed to be admitted to an inpatient ward
and was not safe to be left alone, the coordinator would have to organise a range of resources,
including arranging an inpatient bed. Part of the process of arranging for a bed was to give the
bed management team an argument for why the individual was in a crisis that necessitated a
bed and not the level of care they were already being provided by the HTT.

Crisis
Crisis is the first of three central concepts that inform the practice of the team. HTTs are also
called Crisis Teams because they are constructed to take on and treat patients who are in an
acute crisis. But what does crisis mean? When crisis is related to the role of the shift
coordinator, as it is above, a crisis means a patient who is no longer well enough to receive
treatment at home. Its general use in the team can refer to an acute situation or an ongoing
presentation of the patient. It can be used to signal that an individual is suitable for home
treatment, but it can also be used as an excuse to exclude patients from being treated by the
team. For example, a series of questions can be asked by HTT staff in an effort to reject or
rescind an admission. Is this person really in crisis? Are we the right team for them? Can they

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be discharged to a CMHT? If this is not a crisis, then why are we getting involved? The use of
the concept of crisis here is not necessarily about defining who is in crisis, but rather
determining who is not in crisis. In this sense, it is mobilised to police the boundaries and remit
of the team. “We are a crisis team but that is not a crisis we treat”. The term remains flexible in
its use among team members.

If you asked each team member to explain what crisis meant, some would, without
mentioning his name, have touched on the original ideas of Gerald Caplan. Caplan defined
crisis as the state when “an individual’s normal coping mechanisms are rendered ineffective”
(1964:40). I do not have the space to look at the development of the concept and track it
through history and into its use in the home treatment team today.16 Instead, it is more useful
to explore what the practice of the team revealed about crisis. A good starting point for this is
recognising that a crisis, at its very base, is an exigent circumstance. It is above and beyond
normal life, and as such it engenders a different way of approaching problems, a different
practice. Moreover, the concept of crisis has a particular temporal component. For instance,
the team relied on a notion of crisis as a short-term window when they could produce change
and create a pathway for an individual to recover. Other researchers of HTTs have called this
a “critical juncture” which suggests that it only extends into the future of the individual
(Hannigan & Evans, 2013). I argue, on the other hand, that a crisis was also defined by the
team as something that pulled the past into the present. When the team worked with an
individual, they reviewed their risk profile and history, and searched the records for some
reference that this was in fact a crisis event for the individual and how long this might last.

The idea of crisis can also stretch back into the past of an individual and at the same time be
present as a spectre within the person’s treatment. The EPJS entries are perhaps most
important in deciding whether an individual was really in crisis or not, or how imminent that
crisis might have been. For example, if the patient had a previous history of taking an

16
For a look at Crisis Theory and HTT refer to Anderson, G. (2006). Crisis Resolution and Community Mental Health:
An Ethnography of Two Teams, Durham University.

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overdose of medication, this history would be acutely present in discussions of how the team
should treat this individual. Did the patient stockpile pills? How many pills were dispensed?
These and other factors, all came into view as risky activities. The entries might also have
determined what potential options were available to the team if the individual became unwell.
In some cases, the notes might suggest that the person was not necessarily helped by long
admissions in the ward or maybe each admission became longer and in the view of the
attending clinicians there was more and more of a dependence fostered on the ward while
under treatment. These things balanced with other factors and the current presentation of the
patient might have led to the conclusion that someone who might appear unwell should be
held by the team outside of the inpatient ward. This balance of factors that play into a
“formulation” of the situation and the subsequent treatment of the individual creates an
environment where crisis becomes a “floating signifier”. Crisis has no real meaning; rather it
derives its meaning by the situation in which it is employed. A crisis can be mediated in other
ways, as the following example will show.

Carter, a psychiatrist with the team, and I saw Scott, a 43-year-old former bus driver. Scott
lived with his wife and children on the third floor of an older Victorian row house, across from
an Overground rail station. Scott had active plans to kill himself on the tracks across from his
house. He told us this as he glanced out his window—a window that provided him with a clear
overview of the place in which he wished to commit suicide. Scott also had an alcohol
problem that Carter explored with him. His alcohol use combined with his previous HTT
experience—one in which Scott had taken an overdose and jumped out of his window—
brought Carter to the decision that Scott needed an inpatient bed. Carter made a call to the
shift coordinator; after a few minutes he turned to me. Holding the phone away from his ear,
he told me that there were currently no male beds in the entire country. Carter turned back to
Scott and explained that it was unlikely he would be able to find him a bed that day.

Carter asked to call his wife to let her know what was happening. Scott agreed to this but
explained he did not want his wife to know he was suicidal. Carter nodded his head as the
phone rang. He chatted with the wife and promptly told her that Scott was suicidal and

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having thoughts about jumping off the bridge over the railway. I glanced at Scott who
appeared shocked. While on the phone with Scott’s wife, Carter made a plan for the team
members to visit the entire family that night. He then made Scott guarantee to him and his
wife that he would be safe. Tears were streaming down Scott’s face. After a short summary of
the situation and some reassurances, Carter and I left the flat.

Later, I asked Carter why he felt it necessary to tell Scott’s wife about the his suicidal
ideation. He told me that the guarantee of safety had not worked out with Scott and the team
in the past. It was obvious that the relationship needed to be reconfigured, so Scott’s wife had
to be brought into that relationship if the guarantee of safety was going to be stronger and
more tenable. He set up the conditions for Scott to commit to staying well and then “changed
his community to enforce this”. Carter admitted that it was less than ideal that Scott was still
at home, but he worked to change the configuration of Scott’s crisis so that it would be more
manageable.

The serious nature of Scott’s crisis was discussed later that day in clinical review meeting.
Despite the need for a detox, the consultant recommended Carter not include the need for a
detox in the request for a bed. The clinical service lead (CSL) reasoned that “it’s going to be
difficult to get a bed”. Aubrey protested, “That’s our recommendation for a bed, if the Trust
can’t find one that’s not on us. Reassure him by getting him on the waiting list”. The CSL
filled us in on how bad the situation was stating, “They’re keeping people in A&E for 48
hours in some cases. If he’s actively suicidal he can call 999”. Here, a crisis that usually led to
an admission to an inpatient ward, became something different as the resources were not
available.

When the resources were available, a crisis could be fixed in the immediate present. For some
service users, the crisis brought them to the team or occured when visiting the team. For
instance, as I walked out for my cigarette one morning, a black man with a shaved head and
wearing a black t-shirt and shorts was walking into the hospital, yelling help at the top of his
lungs. He approached me, singing loudly and stopping in front of me. He asked me for water

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by making a bottle tipping motion to his lips. He then dropped to his knees in front of me and
made a motion with his hands as if holding a sword and starting at his left side, moving his
hands over to the right side and then curved them up to his sternum. I recognised this as a
mock Japanese ritual suicide seppuku (harakiri). As he completed this ritual, he asked for
water again. I went back inside to find water and a team member came in, confirming that one
of the HTTs patients had arrived and was acting strange. The consultant and CSL went off to
find him and later made the argument to bed management that he was “promoting a negative
response from others” and therefore was a danger to himself. This justification was a stretch as
he was not necessarily provoking a negative response; rather he was acting mad in public.
Here a crisis was constructed around the individual for the purpose of acquiring further
treatment.

Crisis is a concept with multiple meanings which depend on the character of the situation in
which it is deployed. The imminent crisis of the man who came to the team base was not one
that necessarily warranted a bed, but it was reconfigured in such a way so that a bed could be
justified. Scott, on the other hand, ended up waiting for nearly two weeks at home to get a
bed; he continued to be actively suicidal during that time. The position he was in was
reconfigured to be less risky (though it was still very risky), that is, it was rendered a non-
imminent crisis because the resources were not there to provide a response that matched the
situation. The team’s ability to keep Scott in the community and safe was a concerted effort
to provide containment based on Carter and the team’s formulation.

Formulation

“… a basic premise of psychodynamic psychiatry is that we treat the person and not just the
illness” (Kassaw & Gabbard, 2002:10)

Treating the person in home treatment is about placing them within their context and
environment and developing a formulation of the difficulties they are facing, which may
include a diagnosis, but goes much further than just a diagnosis. The ability to view a person

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and their difficulties in situ is what can make home treatment so perspicacious, but it also
creates a reliance on experience and good practitioners. The concept of formulation is difficult
to define as there are no set or agreed upon definitions; moreover, writing on the subject has,
until recently, been sparse, and there are many different therapeutic modalities that use
formulation in different ways (Johnstone & Dallos, 2006; Mace & Binyon, 2005; Owen et al.,
2014). To explain what “formulation” is, it might be best to begin with what it is not.

Formulation is not a psychiatric diagnosis. Diagnosis is primarily an act of naming “what this
patient has in common with others”, rather than identifying (as formulation does) what sets
this patient apart from another, what makes this presentation and response to illness/disorder
unique (Mace & Binyon, 2005:417). That being said, formulation does have a basic structure,
as identified by Lucy Johnstone and Rudi Dallos (2006:11):

All formulations:
• summarise the client’s core problems
• show how the client’s difficulties relate to one another, by drawing on
psychological theories and principles
• explain, on the basis of psychological theory, why the client has developed
these difficulties, at this time and in these situations
• give rise to a plan of intervention which is based in the psychological processes
and principles already identified
• are open to revision and re-formulation.

Formulation uses a patient’s personal history (among other sources of information) to identify
how a person has felt and responded to similar situations in the past. This makes formulation
dynamic and predictive with a flexibility that allows it to utilise tertiary information like
counter-transference. The formulation includes a diagnosis, from the International Statistical
Classification of Diseases and Related Health Problems (ICD 10). However, it is not reliant on
this and some have used the term to move away from a static model of disorder by using
psychological theory to help explain the patient’s reaction (G. Butler, 1998; Perry et al., 1987).
It uses this information to develop a formulation of the patient’s illness that can predict their
reaction to current and future events/relationships/stressors (Mace & Binyon, 2005). The
predictive work in the HTT is accomplished by using psychological theories, the dominant of

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which tends to be psychodynamic theory. It is from this psychological theory and formulation
that an intervention is constructed and then put in place. The HTT intervention can span
elements from across this formulation, expanding beyond a psychopharmaceutical-centric
approach to illness, by including: cleaning or organising a flat, debt assistance, brief
psychological therapy, and other approaches appropriate to the situation.

A formulation is primarily a way of thinking about and through the complexity that lies at the
heart of each patient who presents to the team. It helps to determine actions. Even in the
simplest of cases, formulation is deployed to map out the possible scenarios in regard to risk (to
self or others) and the possibility of culpability should the worst happen, but also to actively
develop a care plan to which the individual will respond. Formulation helped the team account
for what might happen if, for instance, a mammogram had come back positive for cancer,
helping them plan a response for the patient if this happened. It might also have helped predict
how a patient might react to a funeral for an ex-partner or another possibly disruptive event.

Formulation is the construction of an understanding of a patient in situ and as such the team
acted through the formulation, more so than the care plan, as the care plan merely prescribed
a series of actions based upon the formulation. However, to build such an understanding of
illness, the team needed to carry out a number of interviews to gather the intricacies of
patients’ early lives and other crises. Fortunately, many of the patients that the team saw had a
history with the mental health services and had already been formulated17 by other services,
negating the need for multiple psychiatric interviews. The team worked to adjust these
formulations with any new information gathered, using them to guide treatment. The team
also saw patients (between two and five a month) who were new to services and had not been
formulated. In that case the team gathered information and began to formulate them.

To find out where such formulating was carried out, I asked Aubrey, who explained:

17
The team used the language of formulating a patient.

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 I suppose the formulation process is – sort of happens at various stages. So often
people come to us and they’ve already been formulated. So, you know, if
someone comes off the ward, or comes from A&E, or because we’re a, sort of,
you know, our most tertiary care service, you can’t access us that easily, you
know straight from your house. So – you don’t – the formulation to some
degree has already taken place. So, first of all you start off with the formulation
(it doesn’t mean you accept it); you start off with the formulation and often the
notes will have – if you take the time to read them – there is often a lot of
thinking and review and discussion from a lot of the people they’d been seeing
because they are not new to services.

Aubrey suggested in the above quote that formulation was a dynamic ongoing activity. Many
professionals who had seen patients, added to these formulations of individuals. Thus,
formulations were developed, (re)shaped, and (re)worked across the life-course of the patient.
While this might suggest that the electronic notes, which made up the formulation, were well
organised and had clear relevance to the client, this was not actually the case. Staff
complained of excess detail, misunderstood conversations, misheard stories, or even assumed
or imagined details. This is why Aubrey later told me that formulation was a “permanent
process, it’s not a process you do and then it’s done”. The idea was to constantly reformulate,
picking up mistakes that might be made or changes in situations that complicated or simplified
matters. To do this, one needed an entire team to be active in the formulation of patients.
Aubrey explained to me in an interview how it was not just the psychiatrists who contributed
but that there was something unique that the CSL, nurses, social workers, and support
workers brought. In other words, the team was constantly seeking to expand the dimensions
of formulation by adding a psychologist and a senior social worker/AMHP on the team.
Aubrey placed himself within this group of clinicians as someone who took on the more
difficult aspects of formulation of people who were perhaps more complex. The team was
always interested in expanding both the process and those who had an influence on this
process.

The team brought in specialist practitioners from other teams that could help to fill knowledge
gaps. For example, the Dialectical Behaviour Therapy (DBT) team sent a practitioner once a
month. The practitioner would review a selection of patients with whom the team was

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working. She would then present an understanding of a chosen patient’s psychological state,
as well as some basic interventions that the patient might find useful. During the presentation,
team members added information or presented different understandings of the patient’s
behaviour with which the DBT team member could work. The DBT example backed up my
understanding of formulation as something that was thought through; a constructed
understanding of the patient’s reality. The process of constructing that formulation was
ongoing and fed into how the team approached their patient. That approach was one based on
an understanding of that patient’s reality, and all of the dimensions of their life whether it was
the physical environment, psychological state, or condition of their body. The team itself
worked as a sort of computational processor for information that helped to construct the
formulation through encounters with the patient. Though senior members of the team and
psychiatrists might have led this pursuit to understand and formulate people, all members of
the team worked together to assemble this information and process it. This left other team
members also thinking through formulation and actively aiding in constructing formulations of
patient crises. With the formulation and an understanding of the patient, what did home
treatment offer to the patient?

Containment
Home treatment staff often refer to home treatment’s ability (or inability) to provide
containment to their clients. “Containment” in this sense is both a psychological term and a
physical one. On the ward, referring to containment is particularly physical, in the sense that a
person is contained within a ward, purpose-built (e.g., lack of sharp edges, ligature points) to
reduce the risk psychiatric patients might be to themselves or others (Curtis et al., 2013). The
physicality of containment is revealed in the ward with the use of large, steel, gunmetal-grey,
airlock doors; large, heavy furniture; locked doors; TVs in locked cabinets; the limitation of
ligature points; and constant video surveillance. This sense of containment can work very well
for some people. For example, Alex, one of the psychiatrists who worked with the team spoke
about how “sometimes, people who are very psychotic and walk into the ward; and suddenly
all the voices go away. There is something containing about the four walls; and the structure;
and having social interactions”. In this sense, he used containment in a much more physical

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and less psychological sense. Containment can sometimes stand in for treatment in this usage.
The ward provides physical containment, but it also provides a daily structure and routine
(albeit interrupted by the chaos that can reign on wards). This containment can be beneficial
and, often times is referred to as therapeutic, despite evidence that wards have and continue
to be less therapeutic or are even “atherapeutic” places (Bowers et al., 2009; Csipke et al.,
2018; Foster et al., 2007; Muijen, 1999).

In the community, there was a different sense of containment that was expressed by team
members. For HTTs, containment was a combination of the physical and psychological. A
person in acute crisis being seen at home was rarely deprived of their liberty and could go out
into the world at any time. Home treatment provided containment by building a supportive
structure and routine around that individual in their home. A client of the HTT knew that
staff would visit up to twice a day between specific times and could also set up phone calls to
check in between those times. Alex, a team psychiatrist, helped me to understand this:

(…) in some ways it’s [HTT] an extension of the community (teams), and in
some ways it’s an extension of the ward. It really does sit somewhere between;
and patients often really appreciate that. Because it’s largely: they experience it
as a non-invasive form of containment where the ward experience is very
invasive.

Alex ignored the invasive aspects of home treatment—having team members enter one’s
home on a regular basis—but he did point out that it was an intermediate type of containment
that had some aspects of the ward and some aspects of CMHTs. There is a physicality to
providing containment in the home, by entering and occupying the space of the home with
the purpose of treatment, the team constructed a space of treatment. The predictable periodic
nature of these visits created a routine, but staff also helped to form a routine outside of the
home visit by encouraging (or discouraging) particular activities. These activities then became
the subject of the next visit, providing a sense of accountability. This routine helped to
construct a space and time which could be used to talk about difficult subjects; the patient
knew that twice a day an individual would come to talk to them and give them a space to air
their emotions, thoughts or other burdens.
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These conversations constituted the psychological side of containment, which emerged in
discussions I had with Miryam, another psychiatrist who worked with the team. We talked as
we walked back to the team base on a warm spring day. I told her that I thought I had a
handle on what containment was and related to her the above understanding. Miryam told me
I had used ‘a more structural understanding of containment that differs from the psychological
definition’.18 For example, ‘I can be containing for a patient by being present in a moment or
by just using my words’. She went on to describe home treatment in light of this. ‘I think
home treatment is about containing the chaos that’s going on in someone’s life and then
packaging it up and handing it back to the patient when they are ready to go. I like to hand it
back to them in a titanium box that can be opened with a key’. As Miryam described, home
treatment could be understood to contain and treat a crisis by returning some form of control
back to the service user. Because this was done within the community, it was a different kind
of containment than the ward; it was not so much physical as structural and psychological. It
might have seemed that the psychiatrists did the work of containment but the majority of the
work that went into containing an individual was actually done by the support workers,
nurses, and social workers. They were the ones that had daily conversations, called to check
in, and developed a deep rapport with patients.

The importance of containment, crisis, and formulation was brought into focus when
examining how the team assessed and took on patients to treat. HTTs are seldom closed to
referrals and must continue to move patients in and out of their service in order to fulfill their
role within the mental health service. To ensure that patients are moved in and out of the
team safely and effectively, referrals are screened for potential issues that can make patients
unsuitable for home treatment. A referral can and often is rejected if the patient in question is
not capable of being contained by the team—the crisis is too much for the team to handle in the
community, or the formulation of the patient suggests that they might not be suitable for home
treatment. I spent two months learning how the assessment and referrals (A&R) side of the

18
I use single quotes here as I was not able to write down verbatim what was said at the time.

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team operated. In the following section I focus on my time spent with Dan, a primary trainer
for the team, someone who almost exclusively works A&R, and one of the four original
members of the team.

Assessment and Referral

In the HTT office, there was a small independent space for the A&R team to work. The
room had a smaller version of “the board” with pending assessments on it. In most cases, the
team took referrals from services like CMHTs, acute wards, or A&Es, almost all of which
came via email or phone. Most of these referrals were for inpatient beds, as HTTs were
responsible for screening all referrals to inpatient beds for potential patients who could be
treated at home. The government regulated this by threatening punitive sanctions should
trusts screen less than 98% of all patients destined for inpatient beds (SLaM, 2014c). Referrals
were screened via reading patient notes or phone calls when prompted by CMHTs,
psychiatric liaison nurses (attached to A&E wards), and AMPHs. The general rule was that a
bed manager would not/should not give a bed to someone unless they had been screened by
home treatment. When a patient had been screened and identified as fit for home treatment
they were assessed by the A&R team.

As a function of its proximity to many different wards, the A&R team also had a practice of
“in-reaching” into wards—searching for individuals who HTT could take off the ward early.
“In-reaching” was the process of sending an A&R member to the wards to inquire about
potential referrals. During my tenure with the team, the A&R strategy was changed to one
that concentrated on increasing patient flow. The idea was to take as many people as possible
off the wards to free up beds and thereby increase the capacity of the wards, which were
stretched to their absolute limit. The strategy was purpose built to provide speed and
movement through the system, and was reminiscent of Lorna Rhodes’s study of an inpatient
unit aptly titled Emptying Beds (1991). The primary focus of the inpatient unit Rhodes was
studying was to move people through the system as quickly as possible and thereby empty
beds. This new strategy used home treatment to admit patients from wards early, while acting
as a safety net should they deteriorate (a function missing from Rhodes’s service). Patients

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were being referred so swiftly at one point that Dan, a team member, had stopped to ask
himself and others if they were moving too quickly, if the patients they were taking on were
too unwell for the HTT.

In-Reaching Triage
Dan took me on several A&R shifts. He was a short, grey-haired, white, British man who had
been working in home treatment since the very beginning. He primarily worked on the A&R
side of the team. He was a mentor-like figure for many of the younger members of the team,
and would often lend out his copy of “the red book” (one of the few home treatment books) to
young nursing students who did rotations with home treatment (Brimblecombe, 2001). Dan
told me once that he thought home treatment needed a close look from the outside because
“it’s a house with no windows”.

Dan was in the Triage inpatient ward every morning at 9am for the handover/ward round. I
joined him and others in the Triage morning handover for one month. The handover took
place in a small room populated by junior doctors, a consultant, and a nurse. After the
consultant entered, the nurse handed out printed spreadsheets of the patients in the ward with
various details including diagnosis, gender, age, team, borough, notes, and physical
description. As the meeting began, Dan leaned over and began translating medical terms in a
whisper for me. Each patient presented in the meeting was considered a potential referral to
home treatment. As I listened and he translated, they began to talk about Tomas, a patient we
saw later.

Tomas is a mixed bag, psychosis plus a possible manic element and personality
traits. These personality traits come out when he threatens to kill himself when
he is offered a depot. He has a history of suicide in his family; three members of
his family have committed suicide in a violent way. He is receiving support in
accessing DLA and ESA and remedying his housing situation. He had
threatened to burn down the hostel he was staying in and the cleaner called the
police, who picked him up and brought him to be assessed. There is a chance
that the bedsit landlord will not have him back.

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The consultant told us that Tomas had appealed his section over the weekend, as he had done
in past hospitalisations. Dan responded by commenting that “if it’s possible, we’d like to have
him on Section 17 leave when he’s back with home treatment, if it’s possible”. The issues with
Tomas as an HTT patient were that he might not have access to a home or money, which
based on a formulation might drive him to a serious attempt on his life. The meeting ended
with an agreement that Dan would assess Tomas and take him on as a home treatment
patient, if the landlord would allow him to return.

Mental Health Act and Sections

Tomas was being held “under a Section” and later told me he had been “under a Section” 10
or 20 times. Being “under a Section” refers to the application of a legal section of the Mental
Health Act 1983. The two most common Sections used were a Section 2 and 3. Section 2,
which had been applied in Tomas’s case, is a short-term “hold” (28 days) or revocation of
liberty to allow for assessment and treatment to be provided on an inpatient ward. Section 3 is
meant for long-term treatment and can be enacted after a Section 2 or it can be sought if the
service knows the individual well. It can last up to six months before it needs to be reviewed.
Under a Section 3, a person can be treated against their will for three months after which a
separate psychiatrist has to sign off on a further period of three months for a total of six
months. It is important to note that a Section 3 comes with a guarantee of housing post-
section, whereas a Section 2 comes with no guarantees.

Home treatment teams are a step down from the wards in terms of the intensity of treatment,
which means that patients under Section 2, 3, 4, and 5 are not receiving services from HTTs.
If a patient like Tomas is under section and goes home with home treatment, he will be
released under a Section 17, which is a type of leave that a clinician can give a service user
who is being held under a section of the Mental Health Act. It can be used for any amount of
time, from a cigarette break outside the hospital grounds to a week with home treatment. The
stipulation that comes with a Section 17 leave is that one must stay in a specified place for the
duration of the Section. A further stipulation that can be added is that they must engage with
the home treatment team (though I am not sure if this was legal or just coercive). If someone

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fails to follow the rules of their Section 17 leave, they should be recalled to the ward. A recall
is carried out by police after a warrant has been granted— provided there is an available bed
on the ward. It became standard practice for inpatient wards to discharge patients to home
treatment and immediately fill the bed that was vacated creating difficulties if the team
needed to revoke Section 17 leave. The pressure that this could put on the HTT could be
immense, especially if a recently discharged person was found to be homeless, dangerous, or
uncontainable. Discharging patients to home treatment was not as easy as calling up the team
and telling them to take the patient home—occasionally wards were under the impression that
this was how it was supposed to happen—home treatment assessed every patient in person
before they took them on.

Assessment Interview
The assessment for home treatment sometimes seemed like a formality as much of the work to
ensure the suitability of the patient had already been done to justify the assessment. This work
involved looking at risk assessments, exploring the patient’s history via EPJS (electronic notes)
to draw out what the crisis looked like, and whether the team could provide containment and
treatment in the home. Issues like violence, a tendency to disengage with services, an
unsuitable home, homelessness, or a past history of not engaging with HTT were unlikely to
lead to an admission to the HTT. Assessment interviews were often described by team
members as giving them a “feeling”, saying things like “that patient gave me a… ‘bad feeling’,
‘good feeling’, ‘uneasy feeling’”. Team members might have been referring to counter-
transference from individuals or perhaps the way the person “presented” (agitated, aggressive,
distraught, etc.). All of these things combined to give a team member an idea about whether
to take the individual on or not. If they remained unsure about a patient or their
circumstances, they usually consulted with the CSL or Aubrey. There could also be conflict
when wards or senior managers pushed referrals on the team and expected them to take them
on without argument. The assessments usually took place in a CMHT, in the home with a
CMHT member, or in the ward like it did with Tomas.

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Dan and I saw Tomas after reading up on Tomas’s history. This meeting was mostly to get a
feel for who Tomas was and where he was in his recovery. Tomas was taken aback by how
quickly he had been told that home treatment was coming to see him. With Tomas being in
the hospital for such a short time it was important to actually ask him whether he wanted to go
home, as some patients were pressured into home treatment to clear space in the ward. In this
case, Tomas reluctantly agreed that he was doing a bit better and could go home.

The assessment usually explained what home treatment was, when they visited, what was
expected of the patient, and how to communicate with the team. The team member would
also give them several flyers on the complaints system, emergency phone numbers, consent to
talk to relatives or other health providers, and a basic care plan contained within an HTT
flyer. For example, Dan had a series of forms and went through these with Tomas during the
assessment. As he walked Tomas through these forms, he leaned forward and pointed out
each section, while writing out a care plan for Tomas on the HTT leaflet. Dan gave Tomas an
idea of what interactions he would have with the team and what they would expect of him.
Dan finished writing the care plan while he talked. He later told me he had a good feeling
about this assessment and that Tomas seemed like he would do well. Tomas accepted home
treatment right away, relieving the pressure that the ward was under to open up a bed. Had
this not happened, Dan would have found himself having to convince the patient (and/or the
family) that he was well enough to be treated at home, something he termed “the hard sell”.

The Sell/Sales Pitch

Selling home treatment was something Dan came back to repeatedly when talking about what
his job was, and how home treatment worked. Dan was an important member of the team,
acting as mentor and primary trainer for many of the younger members. His experience
stretched back before home treatment to the 90s when he was working to expedite patients
through the wards and into the community teams. Around the year 2000, he was approached
by a manager who told him about home treatment and its development, later offering him a
job in an HTT.

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Dan explained to me how home treatment had gone through a metamorphosis. In the
beginning he had to aggressively sell home treatment to risk-averse clinicians. Over time, as
clinicians became more comfortable with home treatment and more pressure had been put on
trusts to find ways to deal with increasing demand, he now found himself selling home
treatment to the patients. At the beginning of home treatment, the pressure exerted by the
Trust was on the team to fill their roster; now there was pressure on moving patients out of the
HTTs roster.

Early on in home treatment, inpatient consultants were petrified to let patients go home early.
Dan learned to quell their nerves by selling them on the benefits of home treatment. He
compared this to charities collecting donations on the street: ‘It’s a hard sell, you really have to
push it quickly and confidently’.19 Dan routinely had to overcome negative predispositions
towards home treatment. ‘It was all about the risk. How could you treat someone at home
when they were moderately suicidal’? Dan claimed that this hard sell had slowly been
forgotten by the younger team members. With the trust now shifting towards a concentration
on creating empty beds and saving the Trust money, the sell had changed; home treatment
was now aggressively pushed on patients. Mere hours after this conversation with Dan, we
found ourselves in the midst of hard-selling home treatment over a short stay in an inpatient
ward. A patient, suffering from severe depression and anxiety, wanted to rest and thought the
best place for some respite from the situation in her home would be the ward. Dan worked to
convince the woman that the home would provide a much better, quieter, and less chaotic
place to recover than the ward. In Tomas’s case home treatment was not the hard sell; getting
him back into his home was the difficult part.

Admission to Home Treatment

I followed Tomas through to his admission to the team. It turned out that although he had a
home when he was admitted to the ward, the Trust had been paying for it since his last
admission two years previously (based on the Section 117 after-care requirement). The Trust

19
I use single quotes here as I was not able to write down verbatim what was said at the time.

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had decided eight months prior to this admission that it was no longer their responsibility and
handed it over to the borough, who ceased payment. This left a rent arrears of £7,840 for
eight months of accommodation at £35 a night. The consultant on the ward saw the sense in
paying for his accommodation, as it would be £500 a night to stay on the ward. It saved the
Trust money as they were responsible for housing after Tomas was on a Section 3. Whether
they should have been paying it for that long is a different question. In the end, the care
coordinator managed to convince the Trust to pay the rent arrears and Tomas was able to go
home with the HTT. To prevent this from happening again, he would have to apply for
housing benefits and prove that he was eligible for it. This was something with which a
benefits advisor was helping him. When things were finally sorted out, he had spent 48 hours
being told that he could go home, he could not go home, he owed rent arrears and would be
evicted, and finally that he could go home again. Once everything was settled, it was time to
admit and present Tomas to the HTT.

The final step of an assessment was for the team member who had taken the individual on to
move them onto the team’s electronic roster and give a handover during the afternoon
handover or clinical review. Typically, Dan walked into the room and wrote a name on the
board with all the relevant information. He then turned to whoever was in charge and told
them that he had a patient to handover and then began by explaining who Tomas was and
how he got there. So, in this case Dan and I walked into clinical review (as it happened to be a
Thursday), he wrote the name on the board, and began.

Tomas is Portuguese, he’s lived in the UK for a little more than ten years; he
suffers from psychosis and possible mania with some personality traits evident in
his presentation. He has a family history of violent suicide with three members
having committed suicide. He currently has issues with DLA (Disability Living
Allowance) and ESA (Employment Seekers Allowance) and is working these
out with James. He lives in a bedsit down in the bottom of the borough. He
allegedly made threats to burn the bedsit down and was sectioned under a
Section 2. We have him on Section 17 leave until Monday, so if you don’t see
him, call the police. He’s a joint visit in the morning. He’ll probably be with us
for about a week. Make sure you ask him about concentration and suicidal
thoughts.

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Concerns were immediately raised by the consultant, Aubrey, as to whether he had enough
money to take care of himself. The concern was that he might become reliant on the team or
that he might drain the resources available to the team. The team’s experience with patients
with no discernable source of income was that they quickly developed a dependence on the
team providing groceries and helping with other aspects of daily living. This could limit their
ability to discharge him quickly or it could destabilise Tomas when they did discharge him.
Dan’s focus was on getting Thomas out of the ward and freeing up a bed, counting on the fact
that home treatment would help soften the landing outside and that benefits and other issues
that were currently putting pressure on Tomas would lessen and be dealt with.

In terms of Tomas’s history, this flew in the face of experience. If these issues had not been
dealt with by that time, it was unlikely that things would change. Lo and behold, less than six
months after Tomas was discharged from home treatment, I bumped into him walking across
the grounds of the hospital. We chatted for a bit and I found out that he was denied residence
despite his being in the UK for more than ten years. After he was denied, he ended up going
into crisis again and was, at the time I last saw him, under a Section 3 (six months of
treatment) on an overspill ward. The decisions that had to be made in this case did not stop
what was a slow process that ended in another admission to the hospital and likely another
stint with home treatment, where he would be assessed, taken on, and presented again in the
clinical review.

Clinical Review
The clinical review was where clinical decision-making was at its most transparent, where staff
could be calm during busy or difficult times, and where hierarchies could be temporary
leveled. It began with Aubrey sitting at the table in the centre of the room with a large binder.
The binder was a summary of the week’s work with each patient: the patient’s SASS (referral
document) and a basic overview of what had been done since they were taken on. A
pharmacist joined the team from the pharmacy on the hospital grounds, suppling the
psychiatrists with drug information and advice when called upon. In a half circle behind
Aubrey were the other team members from the morning and afternoon shift. To the open side

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opposite me were the rest of the psychiatrists, team members, shift coordinator and other med
students on whatever chairs they could find or drag from other rooms. In total there were
usually between 14 to 20 people in the room. Aubrey explained that some aspects of clinical
review were “not ideal”:

There is not a large amount time. Not everyone’s there; often people are also
preoccupied with finishing their notes. They get tired and other things, and so,
it’s not a sort of space where you’ve got lots of time. And everyone around –
and everyone is highly motivated to contribute. It can’t really be like that I
suppose, without quite a lot of time and cost implications; it would be hard for it
to be like that. But you’d hope – and what I really like in clinical review, is you
say, “has anyone seen them” and, “does someone have something to say” and
someone says – tells me what’s going on very clearly or advocates a position
very clearly.

Time was in short supply in the clinical review, in fact many ran over the suggested length of
two hours. I can use some basic math to unpack what Aubrey pointed out above. If the
capacity for the home treatment team is 36 patients and you divide that by 120 minutes, you
are left with 3 minutes and 33 seconds per patient. If you were to add an extra hour, it would
give 5 minutes per patient. Obviously, this is too short of a time to discuss patients adequately.
In practice, complex cases could stall discussion and decision-making processes, using time
that might be spent on others.

Clinical review was also a focal point for the leadership role that Aubrey had in the team, and
where the full range of Aubrey’s responsibilities were on display. He described his role as the
clinical leader on the team, which he linked to an oversight, guidance, and supervisory
function for psychiatrists, and the team itself. He maintained regular surveillance over the
team and its patients by reading notes and monitoring progress from afar (and up close by
seeing patients). The decision-making process however, was not necessarily a top down
approach. Aubrey mentioned in the quote above that he was constantly looking for feedback
and direction from his staff to guide decisions. This was done through team members
advocating on behalf of service users interests as well as raising concerns that they might have
from seeing patients.

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This information provided by staff was structured around what the team “needed to know” to
improve treatment, move the patient on to the correct CMHT, or assess whether the
individual was well enough to be at home. Decisions were informed by the three fundamental
concepts that structured the way that Home Treatment operated. Each of these concepts
came with a set of questions that followed from their mention. The first was crisis. Was this a
crisis? What kind of crisis was this? What were the elements that affected this crisis? Who
were the actors involved in this crisis? Second was the formulation, which was a predictive
analysis of the person’s history, present and future set within the context of the present crisis.
This raised questions about the history and presentation of the individual and their
environment. It also allowed for the team to discuss how a patient might react to certain
scenarios and take a more predictive overview. The third was containment, which refered to
what the team could offer the individual at the most basic level—which raised questions
around how the team might intervene to provide a sense of containment for the crisis.

These questions were developed and answered in part during a clinical review, where team
members could advocate for particular avenues of treatment or interpretations of behaviour.
Information was then fed through the care plan for the patient. The linkages between the
home visits, pharmaceutical treatment, psychiatric expertise, psychological expertise, and
practitioner experience came together to dictate the next steps in treatment and the direction
of discharge. Team members helped to fill in the blanks and argued for a particular
understanding of patient behaviour, helping to develop a broader formulation of the patient.
They advocated for aspects of treatment that they believed were going to help the individual
(and sometimes the team). These decisions and revamped care plans then became the basis of
future home visits.

Home treatment is a service that needs to maintain a flow of patients in and out of the team to
continue to play their role within the larger mental health service. In order to do this, they
have organised themselves around three basic concepts that help them to identify patients
they can treat and reject those who are inappropriate for home treatment or who need a

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higher level of care. In treating these patients, they identify the crisis, (re)formulate their
difficulties, and work to provide containment, eventually handing control of the crisis back to
the individual as they leave the team. Decision-making in the team requires a leveling (of
sorts) of hierarchies, providing the best opportunity to understand the individual in situ and
create an approach that moves them closer to recovery and links them to the next team to
whom they will be discharged. All of this is done under acute pressure from various sources
around them. The most important aspects of this process and most impactful interactions
happen during the day-to-day home visits which form the backbone of the care that HTTs
provide. The following two chapters detail an anatomy of a home visit in chronological order.

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Chapter 5: Anatomy of a Home Visit: Part 1

When I read through the many studies that have been published on home treatment or
services like it, I found a lack of focus on the actual day-to-day practice. I wondered what
such practice would look like and just what the “treatment” in home treatment team might
mean. This and the following chapters aim to provide the reader with a step-by-step
breakdown of HTT practice, an anatomy of a home visit. This will build upon the
understanding of practice that I began in the last chapter and provide a foundation for an
analysis of how scarcity and austerity affect this practice later in the dissertation.

In this chapter, I break down a home visit into its constituent parts, organised chronologically
and in a linear progression. I begin by looking at preparations to go out on a home visit.
Following this, I concentrate on how the team created a space of treatment within the
patient’s home, paying careful attention to how practices of hospitality, emotional labour, and
containment emerged to construct this space. I then build on this by examining how this space
of treatment could be both constructed by the team and co-constructed with the patient.
With this in mind, I turn to issues that might disrupt the space of treatment, examining the
process of building rapport and the balance between hospitality, emotional labour, clinical
language, and other aspects of a home visit. I explore this concept of balance further through
the team’s use of mental state examinations and explorations of risk. Finally, I look at the
team’s use of supportive counselling in light of the other aspects I have covered.

Preparing for a Visit

Each home visit was expected to begin by “reading up on a patient”. This required team
members to access the electronic note system, aiming to get a feel for who the patient was:
their difficulties, social/physical environment, relationships, personal history, and what type of
situation they might be walking into. They might also be able to plan to pick up where
someone left off—for instance, have a conversation about something a patient had expressed a
need or desire to talk about in their last visit, or confirm that the patient had followed the

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advice of the team member who had last seen them. Unfortunately, the more visits team
members were allocated, the less time there was to read up on patients. In other words, as the
team became busier, the ability to properly prepare became increasingly difficult. As team
members told me, one could never be truly prepared for what might be behind that door,
there was always an element of risk involved. You could mitigate this by reading up on the
patient, but this was contingent on actually having time to read the notes, and the notes being
a true reflection of what was happening.

Despite having done away with paper notes in favour of an electronic system, medication
information was still handwritten on paper charts. The reliance on hard copies of medication
information was a commentary on the often inconsistent quality and veracity of note keeping
across the Trust, something that was unanimously agreed on in the HTT. Team members did
have strategies to get around this, as one team member explained:

if I want to go see someone and the SASS20 is shit, I’m now going to say: right,
who is the best person who writes notes. ******, right, has ***** seen this
person. And I will go and have a look about what they’ve written. Because to
say: “settled in mental state”, “mildly psychotic” does not mean anything. I
mean, maybe euthymic means not up or down, but mildly psychotic, stable in
mental state? What is stable in mental state? What does that mean? Doesn’t
mean anything.

The above strategy helped the team member to find a reliable and trusted source. However,
the quote also reveals a greater concern with the language used in these notes. In addition to
this there were frequent problems with notes being copied and pasted from previous entries,
which happens on a consistent basis with entries from the ward. On occasion, team members
discovered that the inpatient unit a patient had been transferred from was continuing to copy
and paste notes to the system from the night before, the error occurring as the patient had not
yet been electronically transferred to the HTT.

20
The SASS is an admission summary that is filled out for every patient that enters the team.

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After a team member familiarised themself with the patients they were going out to see, they
collected the necessary medications, charts and other items that might be needed and
travelled to appointments, notifying patients of when they would arrive if necessary. Home
visits were typically conducted between the hours of 10am and 12pm and 6pm and 8pm;
however, visits could stretch much longer than these hours depending on the business of the
team or demand of the situation21.

Entering the Home

I don’t think a lot of staff stop to think about the process that they undertake when they enter a
patient’s home. That is, that’s their personal space and they would not normally have people
coming in to see them from mental health services, and that you need to be very deferential and
very mindful on how you impact on the patient within the home environment; you need to be
very respectful and treat them as you would like to be treated yourself.

-Team Member

The quote above was provided by a team member and is meant to serve as a reminder that
there is a significant difference between the ordinariness of inviting a guest into the home and
the extraordinary impact of inviting a mental health professional into the home. Crossing the
threshold into the home creates a new social relationship with the space of the home and the
people in that space. This relationship would ordinarily be one of hospitality with the
normative roles of guest and host, though these roles are not conducive to developing a space
of treatment in the home. In the case of home treatment, the relationship is noticeably
different, and this difference begins at the doorstep. A team member reminded me of this
point saying:

It’s important to remember that you are possibly the first person that will enter
this person’s house in weeks/months; you’re a stranger. This person is in crisis,
and possibly in a bit of distress. It is hard for them to know who or what is safe.

21
If there is a crisis, a patient cannot guarantee their safety and a bed cannot be found for them right away, team
members will often stay with the patient until there is a change in either the plan or the patient’s condition, being
relieved by other team members when their shift finishes.

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The first step was to make sure that the
person knew who you were and that you
were not there to cause them harm, as the
team member above cautioned. To aid in
this, staff brought out the badge and lanyard
which was emblazoned with the NHS logo
and the Trust’s Logo, as well as a photo of Figure 1

the person to whom it belonged (see figure 1). This was a universal sign that the strange people
on their doorstep were not there to harm them and it was common for them to ask to see it
more closely. Occasionally patients requested that team members did not openly wear their
badges in view of the neighbours for fear of exposing their mental health status or drawing
attention to themselves.

The second part of this process was for the team member to introduce themselves as a
member of the HTT and inform the patient they had come for a visit. A team member
described part of this doorstep process below.

I’m going to be kind of quite friendly, quite warm, quite open. Making sure that
I have eye contact, making sure I’m kind of, sort of responsive to them; I’m
kind of with them and thinking about them. Making sure that I know who they
are and letting them know who I am and never assuming knowledge.

The team member mentioned being warm and friendly, and treating the patient as someone
who was in control of the situation; essentially, he was managing both his and the patient’s
emotions. The management of emotions/emotional labour was a crucial element of the home
visit and creating a space of treatment. Emotional labour, as coined by Arlie Hochschild, is
defined as the need for an employee to “induce or suppress feeling in order to sustain the
outward countenance that produces the proper state of mind in others” (1983:7). Hochschild’s
study looked at airline stewards making an effort to control their own and others’ emotions in

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an environment where emotions can get out of control22. Throughout visits, team members
were required to regulate their emotions and feelings to bring a steadying calm to the
interaction, helping both to create a space of treatment and to develop a sense of containment.
A team member described this.

Not all the time, but quite often you get from patients what you bring to them,
you know, so if you come to their house in a highly anxious state: “What?
What am I gonna find here?” Then often what you get back is agitation. (…) if
you bring relative calm and relative compassion to a situation, people respond to
that. They know that it’s genuine I think. Yeah, sometimes an illness process
takes over doesn’t it – you know, and it’s quite visceral and obvious when
someone’s mania has overwhelmed. (…) I suppose that you know people are in
crisis, but what you bring to them either heightens that or reduces that.

Team members were not just managing their emotions; they were also looking to read the
faces, to retrieve cues of the mental state of the patient. When the door swung open, they
asked themselves, “What’s the face saying, is it saying, ‘come on in, welcome to my home’ or
is it saying ‘who the hell are you and what do you want?’” They also look at the patient’s
clothes, reflecting on: “How are they presenting?” “Are they appropriate?” “Is it hot out and
they are wearing eight layers of clothing?” “Are they only wearing a towel?” Team members
were always interpreting and analysing what they were seeing and what was going on around
them. The person’s clothing, face, demeanour, and the home itself, all became potential
indicators of illness or recovery. Moreover, team members paid attention to the interiors of
homes for emotional cues. Someone reflected:

What does the place look like? Is it a tip, has it been recently cleaned? Are you
allowed in? I suppose is another thing, because a lot of time it’s sort of like:
right, let’s get this done so you can go, and you’re not even getting past the
threshold. So yeah, I mean sort of, is there anyone else home?

22
There are other parallels here as well. Hochschild finds that the role of emotions management becomes more
difficult for stewardesses as their time is more tightly controlled and the amount of staff on flights are cut back.

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Team members did not just analyse the space but also reacted to this space and the way they
did that helped them to create a new relationship with the space. Even the most obvious and
inane of activities involved in entering the home—taking one’s shoes off—helped to reshape
the use of that space. Many team members walked straight through without taking their shoes
off, negating the threshold of the home and creating a similar relationship that a patient might
have with council worker fixing a leak. There was a sort of “doorstep politics” that went on
between patients and practitioners, and this became more evident when patients, for whatever
reason, were unwilling to allow entry to their home.

Creating a Space of Treatment

The challenge of working inside a patient’s home was to establish a space of treatment where
the authority of the health practitioner superseded the social relation of hospitality and the
position of a guest. Clients of the HTT, so long as they were not on Section 17 leave, could
ask, at any time, for the team member to leave. They were under no obligation to listen to the
team or engage with the team. Yet, they did listen and engage; the authority of team members
persisted (for the most part) because of their relationship to the space and the patient. Ian
Tucker has argued that psychological states, habits, and actions work to constantly produce
and reproduce the space of the home (2010a; b). Once a team member stepped inside the
home, they contributed to the experience and relationship that the patient had with that
home. The HTT also helped to reshape a space within the home for a set time into a space of
treatment by using a set of practices that created a linear progression of treatment.

Once team members stepped into the home, they worked to temporarily reconstruct the space
through practices like showing the badge, not taking shoes off, and managing their emotions
and those of the patient, all of which signalled to the patient that this was now a space of
treatment (Bowers, 1992; Magnusson et al., 2003; Öresland et al., 2013; Öresland et al., 2008).
Beginning the visit by picking up where the last visit left off also called on a linear progression
of treatment and drew on prior visits for enhanced legitimacy, especially if this was a new face
for the patient. Each of these practices worked to reconfigure the relationship the team
member had with the patient and space. In doing so, they not only negated the social relation

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of hospitality and created a space of treatment, they also manufactured an authority within
that space (Öresland et al., 2013). Other authors have written about hospitality and district
nursing, noting that the acceptance of tea or other social niceties changes the nurse’s role
within that interaction, from professional to friend (Bowers, 1992). In the ethnographic
example below, I document such a shift between the role of practitioner and guest.

Amy, a nurse with the HTT, and I went to see a 63-year-old Ghanaian woman suffering from
psychosis named Valerie. At the time, she thought that her husband was part of a cult that
was casting spells against her. When we arrived, we sat on chairs placed in the space between
the living room, kitchen, and hallway.

Valerie was very distressed, enough that Amy dispensed two diazepam to calm her. We
talked about what was going on in Valerie’s life and tried to offer alternatives, explaining that
her husband did not steal photographs to give to a sorcerer; rather those photographs were lost
in the process of sending various things home to Ghana. As we worked to calm Valerie down,
Amy stepped out of the room to call the team to cancel our other visits and see if there was a
bed available. Amy returned, telling us that a doctor was in the area and was coming to see
her. Valerie immediately thought that she was going to hospital. She told us that we did not
have to call the cops and that she did not want her neighbours to see her being dragged away.
Amy explained to her that the doctor was coming and that we would not force her into
hospital unless the doctor deemed it necessary.

As the hours rolled by, Amy asked Valerie if she had done any cooking recently as she was
quite small and had been fasting. The husband shuffled off into the kitchen and closed the
door, only for it to open again with two plates of food. Once the food was given to us the
dynamic in the room immediately shifted. Valerie and her husband were laughing and fussing
over whether we had had enough food and whether it was too spicy for us. In an instant, it
was as if they were a happy couple again, brought together as host and hostess to the two
guests that they were entertaining. As the doorbell rang, the mood shifted once more as a
serious and stern psychiatrist strode into the room. Valerie reacted instantly by composing

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herself, sitting straight, and shooing Amy out of the arm chair, and the psychiatrist into the
chair. Valerie was focused on downplaying her symptoms and putting on a mask for the
authority figure that was now residing in the armchair. Amy and I were not only cut out of her
field of vision but the conversation as well. We were merely bystanders.

The example reveals the dynamic nature of both the shifting boundaries between guest and
professional and the presentation of patients. Situations, interactions, and moods can shift
quickly in home visits and the management of emotions is key to the production of a space of
treatment and the authority that goes with that space. Amy and I lost control of this by
slipping into a guest/host relationship. The psychiatrist who strode in with a serious
demeanour recreated a space for treatment (without Amy and I) and engendered a serious
response from Valerie. This response was also an effort to reshape the space by moving Amy
and I to the periphery and the psychiatrist into a place of authority, helping to co-create a
space of treatment.

Co-creating a Space for Treatment

I wait in the hallway until they’ve shut the door and then follow them to wherever we’re going.
If I’ve not met them before, if I’ve been there a couple of times, I’ll ask if, I’ll say are we going
to the lounge and then if they say yeah, I’ll just go. But it’s just, you pick up from the person’s
behaviour, you know, sometimes patients they don’t want to lead you somewhere they just say
oh it’s there at the end. So, you’re guided by the person really and then I ask, I always ask to sit
down.

-Team Member

Patients often helped to co-create the space of treatment in the home. The quote above
captures a team member talking about doing this. The majority of the time the patient chose
where the visit would take place. However, the home was something that could be useful in
understanding a patient’s illness, and to do so the team member might attempt to position the
space of treatment in a particular place. For example, asking to look at where they sleep might
lead the team member to find out the patient was sleeping in a bathtub. The patient could also

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try to actively shape what the team member saw by directing them towards a space that had
been made up for them. In the following example, a client name Christina related her
experience of having team members in her home and her attempt to provide an environment
that was manufactured.

Cameron: Was it strange having mental health professionals in your house?

Christina: I suppose a bit. I was more concerned that my living room was tidy,
because it’s an odd thing to invite somebody in. But I got quite good at saying,
you know – Will would go answer the door, I’d be sitting on the sofa, you – I’d
make sure it was a calm environment already and clean and tidy and then… But
no, it was ok, you know, surprisingly, surprisingly fine or more than fine. It was
good to see somebody, a familiar face, and that didn’t happen a lot the first few
days, but then a couple of people I’ve met before would come and that was
reassuring.

While Christina only tidied up her home to make it presentable, team members noted that
other service users went to great lengths to rearrange their flats. One recalled walking into a
home with a desk and chairs arranged like a job interview where the team member was
interviewed by the patient. There was an active shaping of the space for interactions that
occurred both by team members and by patients. Sometimes the space was already set up
with chairs in a configuration reminiscent of a doctor’s office with family members waiting for
the team members to be seated. As such, team members were often assessing the
environment, deciphering it with a psychiatric gaze.

So, when I go into someone’s house, I always look at the living environment,
that’s my thing. Obviously how the person is, how they’re interacting with me
being in their own space, as well. Looking around gives me an indication of how
well they are able to manage where they are living. It could be a dump; it could
be a result of them becoming unwell or it could be that’s just how they live.
Don’t know, so all of those things I’m kind of absorbing and taking in. Who else
is in the house, you know, what’s the interaction with that person in the house?
Could be a child. Is the child coming up to the mom and are they interacting
with the child? So I look at lots of different facets as to how that person’s
functioning with me in their space, because you can’t ignore that. It’s not the
norm to have strangers come into your house and asking all of these personal

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 questions. I think it would piss me off to be honest. I’d be the worst patient, I’m
sure. You know, by and large a lot of people do cope quite well with that.

There was a commonly held belief by the HTT that the home itself revealed something about
the mental state of the patient who lived there. This was supported by Clare Cooper Marcus
who explored how people can communicate aspects of themselves through the appearance
and personalisation of the home space (2006). Ian Tucker took a different but complementary
approach, arguing that the home was produced by habits and practices that could reflect,
produce or alter psychological states (2010a; b) For the HTT, a disordered home was a
disordered mind. The quote above mentioned the gaze of home treatment members assessing
the landscape of the home. This landscape could be brought into conversation, furthering the
construction of a space of treatment. For instance, a blanket over the TV could be brought
into the conversation to explore whether the patient believed the TV was specifically
speaking to them. The landscape of the home also included other people, besides the patient,
who resided in the home and the relationship that they had with each other. There were times
when other occupants of a home, such as brothers, sisters, landlords, or friends, might have
been taking advantage of or mistreating the patient in question. This exploration of the home
through questions prompted by objects in the home was part of the basic questions that were
asked during a home visit.

Building Rapport, Asking Questions: Empathy versus Professionalism?

(…) The strict boundaries between being a professional and being empathic are a little bit
different. So you know in mental health, empathy is a kind of necessary part of the job in a way
that is somewhat different, and so, you know you can’t be empathic if you’re super formal. But
clearly you can – very clearly, there’s a risk of crossing a boundary if you’re too empathic and
you lose the clinical distance which the patient may need and want, and then there are all sorts
of issues and other issues as well. So, but I think in home treatment – it needs to be somewhat
policed. (…)

-Team Psychiatrist

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The psychiatrist here commented on a difficult aspect of visiting patients at home. He showed
that there was a certain empathy that was necessary to develop a good rapport and ask
questions and receive meaningful answers. There was also a boundary that this empathy
rubbed up against—too much empathy could reposition the practitioner and client
relationship. Each visit started with some basic questions that guided the Home Treatment
member in the conduct of the visit, which later progressed to a mental state assessment to
gauge what stage they were in recovery. The visit’s success hinged on the ability of the team
member to make the patient feel comfortable; to build a rapport with that patient or call on a
shared history to create a rapport; and then to present a set of questions in a way that made
the patient feel compelled to answer. Rapport and empathy were practices that contributed to
a space of treatment. One way to develop rapport was to start with some “problem free talk”
by using an object in the room to excite a regular conversation. Problem free talk is a
conversation that doesn’t revolve around the reasons for the patient presenting to the HTT.
They then used this to build a bit of rapport before asking more personal questions. For
instance:

I love a bit of problem free talk (laughter). Yeah, I think there is [room for
problem free talk] because I think a lot of the criticisms of our style maybe in
the past has been “All you do is come in and give me medication and go”; and I
think it’s probably not quite as brutal as that but it’s probably a fair
representation of some of the contacts we have. Where we are going in,
obviously supervising meds, and thinking that that’s what that person might
want as well – want us to go. But lots of the time I think it’s just nice to have –
just to normalize it and sit and have a chat about the Olympics, something,
anything, you know. That might be the only human contact that person has all
day. So if all you do is go in and say “right, there you go, there’s your PM
meds, there you go, good night”, I mean why not?

A valuable point is raised here—with which many patients agreed— which is that some visits
were far too short and too focused on medication. Some team members viewed medication
focused visits as too clinical and less therapeutic, almost as though clinical language disrupted
the perceived warmth of the home. When they talked about this, a natural/artificial divide
emerged, where a “natural conversation” could help to make the patient relax and feel as
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though they were being cared for. A non-clinical, natural conversation was also beneficial for
those who were socially isolated, as it may have been the only contact with another person the
patient had all week. Some members of the team could disguise clinical questions within a
“natural” conversation. For example:

I’m looking predominantly for the person’s ability to conduct a conversation

with me, which I would regard to be within the parameters of normality. I’m
not looking to run through – well correction, I am looking to run through
something of a checklist – but I’m hoping to do that by stealth, really. I’m not
looking to present the person with a list of things that I need to tick off or cross
off and think about whether they are doable or not. I think my experience tells
me that patients generally dislike that. They like to engage with somebody with
a bit of spontaneity, warmth, a bit of um, the conversation flows as it would
outside of a health setting.

Here the team member made an effort to “naturalise” the conversation and still find answers to
the basic questions he needed in order to gauge how well the patient was doing. The team
member also mentioned addressing the care plan in a similar fashion in this interview. He then
turned his focus on himself and his position within the interaction with a patient, as becomes
apparent in the excerpt below.

They know that I’m assessing them, and I know that they know. I think
patients are not stupid. Just a sense that the conversations a bit warmer and a bit
less clinical. I think I’m, possibly sometimes, as we all are, guilty of bringing sort
of clinical language which I have to backpedal on sometimes. And remind
myself that I’m in somebody’s house and they want to engage with me as a
human rather than a textbook, but I think that’s what I’m looking for.

The natural/artificial divide is expanded on in the above by identifying clinical language as

artificial and for the clinic, not the home. This creation of a space of treatment offers the
warmth that might be expected within the home but at the same time accomplishes the goals
of treatment. This reveals how one might use language in an effort to conceal something that
might be considered clinical and cold, or conversely use clinical language to add authority to
their advice. This is a much more deliberate and thought out way of constructing a space of
treatment, but, it runs up against boundaries that must be maintained for the benefit of both

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the patient being treated and the practitioner. It is possible to manage a professional empathy
without slipping into the role of a guest or a friend, while still managing to build a rapport. The
following account from a team member reveals that there was a line that was often skirted as
team members “give a little of themselves”.

(…) Generally, I try to introduce a bit of humour to it as well, even a little bit of
myself. You know, if they asked me if I have kids I say, “I’ve got one daughter”
yeah, whatever. You don’t divulge too much, but you know you have to give a
little bit of yourself, I think. Try not to get upset by the situation they might be
in.

I’ll give you an example again, a few years ago my mother died; seven years
ago. About a year after she died, I went to see someone whose mother had died
just a few days beforehand and was being buried the next day, and that was
very difficult to hold myself together, hold back a few tears. And she sort of
said all the things about not seeing her mother again or hearing her voice again,
and they were things I was really finding difficult. But I had to keep together.
So you’re always very aware of being professional, but without being too
officious about it.

The team member was walking a fine line, maintaining a boundary by not sharing too much of
herself, but sharing enough of herself to maintain a sort of naturalistic conversation. This
recognition of aspects of the self in the other could give team members a heightened stake in a
patient’s recovery, but it also included a deep emotional labour that was much more personal
than some would have liked to admit. After a rapport had been constructed along with the
space of treatment, the next step in the visit was for the team member to examine the patient’s
mental state.

Mental State Examination

With most of them (patients,) you start with problem free conversation to get the rapport and
make them to relax, and then you start asking them questions that if, for example, if he is
someone who is having a psychotic episode, then your questions should be centred around
mainly about the psychotic symptoms: whether you are experiencing any auditory
hallucination, or that they are experiencing any tactile hallucination, any olfactory, you have
to go through all of them with them.

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 -Team Member

The Maudsley Handbook of Practical Psychiatry gives the definition of a mental state
examination as “a snapshot of a patient’s behavioural and psychological functioning” (Owen et
al., 2014:60). The above quote describes part of the approach to doing a mental state
examination during a home visit. He began by building a rapport and then moved on to
questions revolving around the senses and potential hallucinations. In doing this, he was
exploring the patient’s sensory experience and the potential symptoms a patient may or may
not have had. There was no standard set of questions in home treatment; instead it was a
conversation that was led by the patient’s answers.

The handbook mentioned above gives a set of “headings” under which questions should be
asked and includes issues like appearance, behaviour, mood, thought content, abnormal
beliefs/interpretations, abnormal experiences, and a host of other aspects of illness (Owen et
al., 2014:60-64). The team generally tried to explore patients’ emotions and experiences of the
world while working to maintain a balance between clinical speak and natural conversation to
preserve the space of treatment. In doing so, they focused on symptoms or issues that may
have been troubling them, for instance, whether the person was feeling safe in their own home
or outside their home, were people watching them, listening to them, did they think they
were special, could they do special things, see things others could not, and so on. They were
looking to track distinct and noticeable differences between what a patient said one day and
what they might have said a day or two later.

The team was reliant on these observations and the skill of the observer to track changes in
the patient’s mental state. In a case where a patient deteriorated while being seen by the team,
that patient’s history would be checked to develop an idea of how the patient might continue
to deteriorate and what this meant for potential risks. Team members often referred to a “rule
of thumb” that the speed of deterioration in a patient’s mental health usually indicated the
speed at which they responded to treatment. If this was the first time they were with services,
the reliance on regular mental state examinations, the experience of practitioners, and

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constructing a formulation was paramount to recognise potential difficulties and risks. The
lack of information might also severely diminish the team’s ability to tolerate potential risks
that cropped up during this deterioration, leading to a rapid hospitalisation if the resources
were available.

A quick way to track deterioration that did not involve a lengthy list of questions are “naught
to ten” scales. The use of “naught to ten” scales for rating mood or suicidality (among other
symptoms) depended on the practitioner’s style and could challenge the balance and aesthetic
that went into constructing a space of treatment. Generally, the patient was asked, “Rate your
mood on a scale of naught to ten”.

I don’t use it (laughter) naught to ten (laughter). When I first started and I went
out on a few visits and I saw the naught to ten in action, I thought “god this is
weird”, but then I thought “is this what I have to do?” So I think I tried it a few
times. Didn’t come naturally to me at all and it just felt really wrong to me.
Some people quite – I think there’s a few patients that we’ve had before who
have said “I don’t know how to articulate how I’m feeling, so if you ask me on a
scale I can tell you and you can gauge from that”, for instance Niall actually
does that. He actually says, he’ll say “I’m feeling a one today” and then you can
– and he’s said in the past what each number represents. For some people it is [a
part of their practice], but generally speaking I’m not a 1-10 person.

Sometimes these scales were requested by patients who had trouble elaborating on their
emotions or who could easily ruminate on these emotions while explaining them. It could also
act as a shortcut, quickly obtaining information in a pressured environment. The difficulty
with the “naught to ten” scale was in its ability to capture a patient’s mood or suicidality. It
was one thing to explain what you meant by “naught to ten”, but it was quite another thing for
the patient sitting across from you to interpret that scale the same way you did. I heard a wide
variety of patient interpretations of the scales that rarely fit the one given. I also heard team
members tell the patient their answer was not correct. Some of the issues with the “naught to
ten” come out in the example below.

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Kate, a middle-aged woman who had a history of stressful jobs and occasionally suffered from
long bouts of deep depression, was asked to rate her mood. We were sitting at a small table in
her kitchen with the TV on mute. Chloe, the team member I accompanied, was trying to
gauge where Kate was in her recovery. Pressure was beginning to mount on the team to
discharge Kate, to avoid reaching capacity. Chloe asked Kate if she could rate her mood on a
scale of naught to ten. Kate told her that she was a four but that she fluctuated during the day.
The four made Chloe curious as to what was happening, as she had been struck by how much
better Kate seemed when she walked in the door. Kate added that there had been quite a bit
of fluctuation the previous week, but this week was a bit better. Chloe then asked how she
might rate her mood in a fluctuation; Kate ignored her question and instead told us she had
called “Solidarity in Crisis” almost every night the past week.

Chloe moved on, asking her how she ended up back with the team after spending a long
period with them earlier in the year. Kate told us about how her employer had rushed her
back to 10- to 12-hour shifts almost right away. There was no gradual return to work, her
employer was clueless, and she was left feeling as though she had been discharged from home
treatment prematurely. Her employer continued to call every day asking her when she would
be back. Kate burst into tears. As she grasped a tissue in her hand, Chloe asked if this (crying)
was how she really felt. Chloe said she remembered Kate being very good at putting up a
social front, but that if this was really how she felt, she needed to say so, because “we don’t
want her to be discharged early”. Kate responded by telling us this was how she really felt.

Chloe, a team member who often relies on “naught to ten” scales, in this interaction failed to
pick up on other cues outside of the scale. In fact, when told about the fluctuations, Chloe
reverted to trying to quantify this through another “naught to ten” scale, which Kate ignored.
Instead, Kate tried to convey how upset she was by telling us that she called a hotline for
people in distress. Chloe only began to clue into how upset Kate was once she began to cry.
Chloe was then attentive and took the time to explore the emotions Kate was feeling beyond
the scale. The scale, meant to stand in for a deeper exploration of her feelings and emotions,
failed to capture the detail necessary in this example. Under normal time constraints, Chloe

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was able to readjust her strategy going beyond the scale. In other situations, where team
members were more pressed for time, the scale could be used as a box-checking exercise,
especially when there may not have been prior knowledge of the patient or time spent to
develop a rapport.

Exploring Risk
Home treatment deals with risk in a variety of ways, including positive risk-taking, but talking
about risk itself can be difficult and potentially disturbing. The importance of rapport and a
sense of when to talk about risk are skills developed with experience. One of the pitfalls to
home treatment are the many faces (many team members) that might see a patient, which
makes it hard to build a rapport. Compounding this can be the sensitive nature of what’s
discussed when a person is in acute crisis and at a high level of risk. The common approach to
risk is to ask a person if they feel suicidal, or if they feel safe within themselves. If the answer is
no, the next step is to ask if they have a plan. If so, this is then followed up by asking about
the plan. The more detailed the plan, the more risk is present. The higher the risk, the more
urgent the situation becomes until it is clear that the patient must go into the hospital for their
own safety.

Davis, an HTT member, talked to me about positive risk-taking. This is the idea that
someone can be actively suicidal but can find a way to be safe for 12 hours. Making it through
those 12 hours can then be turned into a positive event and built upon, leading to another 12,
and another 24 and so on. This is positive risk-taking and it is what several members of the
team insisted that home treatment is founded on. Davis gave me an example of an incident
with a patient. In this case, both he and the team member who accompanied him had not met
this patient. There were no beds available on the ward and despite conditions being difficult,
Davis, a veteran with the team, was able to create a plan whereby this patient could be safe.

The patient had guaranteed that he would be safe earlier in the day but then had superficially
self-harmed. The patient called an ambulance and the police arrived first. He had also called
the team and told them he was feeling unsafe, so when the team members arrived, the police

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were in the process of waiting for the ambulance to take him to Accident and Emergency.
Davis had a difficult task in front of him because the man had already broken one promise by
self-harming. Davis checked his options and found that there was no way to admit the man.
This meant they had to rely on other signs that this man would not take his own life. In this
case the patient had talked about looking forward to watching a football game the following
Saturday. The ability to be future-oriented signalled to Davis that he could proceed to setup a
plan for what the patient would do that night until the team came to see him again in the
morning. Unfortunately, the man ended up going into the inpatient ward days later and
committed suicide. The HTT was involved in the investigation that followed but was relieved
of any blame.

A similar situation with a patient who was known by the team and who rapidly deteriorated
during treatment took a different path. Leon, a young man with mania and a complicated
situation with a risk of violence, was seen by a senior staff member, numerous times during
which she engaged in lengthy discussion with him about going into hospital. She underlined
an important point in her discussion with Leon for me.

So yeah, I kind of learn a lot from that because it’s a demonstration of how
important it is to have a rapport with somebody, not just when things are going right
but when things are going wrong. You can track that open and honest dialogue and
they actually trust what you are saying, which is what he said to me. That he
trusts what I’m saying, but he didn’t agree with it, naturally, but he did trust
what I was saying.

This team member was able to maintain a rapport with Leon and build the suggestion of
hospitalisation into the conversation over time. She did so in a way that preserved his sense of
self-direction and promoted trust in her ability to help him make good decisions. Here she also
underlined having an open and honest dialogue with someone who was being treated
regardless of the direction in which they were heading. The ability to link each visit and each
discussion and build upon that is powerful in creating both containment for the individual and
reinforcing a space and linear progression of treatment.

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This repetitive dialogue about a person’s mental state can also have a negative effect on
patients. How many times can someone sit and answer the question of whether they are
feeling suicidal, before they either return to that thinking or get frustrated? Risk is a constant
preoccupation in home treatment and fixating on it creates a paradox.

There’s certain questions that you have to ask aren’t there? Unavoidable, you
have to be able to be quite skilled in asking about problems, you know, it’s one
of the great paradoxes of home treatment. You’re trying to help people recover,
and yet you’re carving a groove in somebody’s mind about what their problems
are rather than necessarily what the solutions are. You know the questions; we
ask about: Have you been feeling suicidal? Do you have active plans? Do you
have active intent? Those only serve as a reminder that the person used to be
that way, or only for – or possibly still feeling that way. (…) I’m pretty
convinced that everyone in the team needs to do a solution focused module of
some kind. Because it’s quite a profound realization if you’ve worked in mental
health services for long enough; the things you use to ask the person to define
what’s going on for them, by which we mean “what are all of your problems at
the moment” and they would have inevitably told 20 people about that already,
rather than, say “you know what, what do you perceive are your strengths and
how are you gonna drag yourself out of the well you find yourself in?” And you
know “what are some of the solutions?” So a different groove is carved
essentially.

This approach about which the team member was talking describes the paradox within home
treatment. Patient viewpoints (addressed in later chapters) reflect this. This is an important
issue, but it remains a paradox, even more so when you consider that referring to past
conversations is a good way to construct a space of treatment. What the team member
suggested above, that other members of the team need to take a solution-focused approach,
was a level of sophistication that the team had yet to reach. It was also linked to the idea that
home treatment provided a sort of supportive counselling.

Supportive Counselling

So, some people obviously just need you to listen to them and validate how they’re feeling, and
sometimes you can help them put things in perspective or get them to think about things a
different way, so that’s just the sort of mental support kind of thing.

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 -Team Member

When a service user first hears mention of home treatment offering supportive counselling,
they often imagine a one-to-one psychotherapy session. What they receive, however, is quite
different and difficult to define. Supportive counselling, for the most part, is listening to
patients’ concerns or experiences and reinterpreting them in a more positive or less
threatening light. For example, a patient recounts walking through a park and having a group
of people laugh at them. A team member might propose that, in actuality, the group were
probably not laughing at her but at something said in conversation between themselves. Team
members can also reinterpret recent or historical events in a patients’ lives into narratives of
progression and recovery, including even the smallest progress. One patient needed constant
reassurance that the things he was doing were getting him on the path back to work. Most of
the contact was comprised of him telling the team member what he had done and the team
member responding to that by placing it within a frame of slowly building confidence to return
to work.

Supportive counselling was not always part of a home visit; for example if a patient was visited
in the evening “you could be going there and eliciting all sorts of stuff and then walking away
from that and that’s quite distressing for that person to manage”. It also might not fit neatly
into a controlled time slot. When you open a conversation with somebody about a distressing
aspect of their life, you need to take the time so that you do not leave the patient in distress.
Each patient, each visit, requires a different approach. A team member summed these points
up quite well.

People are different obviously, so you’re going to speak to them differently;

their illness is different, it manifests in the self differently. Some people, you
need to be a bit firm. You say, “you need to do this, if you don’t do it we’ll
come to wash you”, you know, other people you say, “that’s terrible” you need
to be a bit more, “there, there it’ll be ok”, you know a bit of TLC, that sort of
thing.

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The team member above separated their approaches into the dichotomy of the warm TLC
caring approach and the “tough love” approach. Another team member pointed out that
despite some members having broadly different styles, some of which did not work with
everyone, every “(…) team needs a variety of different characters, doesn’t it, in order to
extract information and achieve the goals on behalf of the patient or to ensure the patients find
something to engage with, to latch on to”. The idea of having many different personalities and
styles is to try and find someone the person feels a connection with and engages with, thereby
having a better chance at a strong rapport. Having a “broad church” of styles and personalities
to deliver them allows for a greater chance of a team member being sent out who connects
well with the patient. Much of this is counselling/talking/listening, but what part of this is
supportive?

What is supportive in home treatment is the unquantifiable, hard-to-describe aspects. It is the

care that is shown towards patients by sitting and developing a rapport with them, by taking
the time to listen to their concerns and hear their distress, and then seeking a way to alleviate
that distress. Supportive counselling is perhaps one aspect of the team that will defy exact
definition or measurement, as it does not fit neatly into a category like delivering psychological
skills might. As one team member warned:

(…) There’s a lot of unquantifiable, touchy feely type of skills that psychiatric
practitioners have. Some of them perhaps don’t even have headings or names
and therefore haven’t even been labeled, so they can’t be measured. You know,
I think that’s the more artistic temperament within me says just leave those
alone, those things you can over analyse, you can try to measure but actually
that might be the death of it.

All of this is connected to the team’s ability to focus on patients and invest time in them.
Ideally home treatment also offers supportive counselling for family members, but in practice
the time is often not available to provide supportive counselling to both the patient and their
family. Time constraints affect many of the aspects of home treatment that have been looked
at in this chapter, from reading up on patients to constructing a space of treatment within the
home.

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Just as there is a linear progression to a home visit, there needs to be a linear progression to
home treatment to build a sense of support, containment, and treatment. Linking visits
together, drawing on past topics of discussion, and continuing conversations helps to create
this progression to a set endpoint. It also contributes to a series of practices that produce a
space of treatment, where the team can exercise authority. There is however, a balance that
must be struck to maintain a hold over the situation; emotions need to be managed, language
needs to reflect the space in an appropriate way, and personal boundaries, though blurry, must
be maintained. In the next chapter, with the space of treatment already constructed, I look at
the way in which the team intervened in patient issues and difficulties. I also look at the way
the team managed to deal with the difficult nature of this work and provide that delicate
balance without it negatively affecting their own lives.

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Chapter 6: Anatomy of a Home Visit: Part 2

This chapter continues to look at the anatomy of a home visit. It begins by looking at the
interventions that the team offered beyond supportive counselling and what happened after
home visits were over. In doing so, I reveal a nostalgia about what the team used to be able to
do as opposed to what they could do at the time. I then look at how the team delivered even
the simplest of interventions, by providing a foundation that the patient could understand and
the tools necessary to follow it through. I explore the team’s use of medication and their
prescribing habits: revealing the pragmatic nature of psychiatric prescribing and the difficulties
that it can cause with comorbid conditions; the use of sedatives to produce a chemical
containment; and difficult beliefs about black patients and “culture” that underscored some
prescribing practices of the team. In the final section of the chapter, I look at the aftereffects
that team members could experience and how approaches to addressing these aftereffects
were felt to be inadequate and did not produce the desired result of reflexive, informed, and
emotionally capable team members.

Interventions, Time, and Nostalgia

This HTT still resembled the original TCL method and, unlike many other teams (Lloyd-
Evans, Paterson et al., 2017), they still retained the ability to provide a wealth of different
interventions beyond supportive counselling. The team delivered a variety of different
interventions aimed at supporting the patient through a crisis and providing them with skills
and advice to avoid future crises. Although the team would have liked to deliver some of the
more intensive interventions that addressed or began to address long-standing issues, they
often found they did not have the time for this. When I list the interventions that occurred
during my time with the team, it is important to keep in mind that many of these were not
daily occurrences and some of them may not have even been weekly occurrences. For the
most part, many of the team’s interventions were basic and addressed major issues that helped
recovery and relapse prevention.

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The team’s approach to treatment involved delivering a set of tools that the patient could use
to recover and stay well. These came in the form of advice and counselling on sleep hygiene,
knowledge about their disorder or triggers, exposure and reintegration into life outside their
home, and other approaches, some of which were informed by psychological modalities like
dynamic behavioural therapy (DBT). The team also intervened on the home itself, helping to
collect groceries, clean parts of the flat/living space, purchase new bed linens, help do laundry
or dishes, plan a budget, phone bill collectors, talk to employers, and occasionally help to cook
a meal. It was important for the team not to do interventions on patients but instead do them
with patients.

The first step in doing interventions with patients is to be a resource for questions, which is
common during a bewildering situation like a mental health crisis. The second step is to guide
the answers to these questions, and to focus the conversation, in order to discover what
interventions might fit with the situation of the patient. Part of the role of the questions is to
collect information to begin to identify, plan, and deliver interventions. For instance, during a
home visit with a woman suffering from depression, anxiety, and fibromyalgia, who seemed
unable to leave the house, a team member I was with followed the basic structure laid out
above. He transitioned from questions about mental state to sleep hygiene advice. He then
opened space for the woman to guide her own treatment, asking, “If we had an hour and we
could help you do anything to get back on your feet that you would usually do, what would it
be?” She thought about this for a few moments and mentioned that she was housebound. She
told us that she could not leave the house because she felt disoriented outside and feared being
lost. The team member returned to the original question, adding that the team could help her
gradually become more confident leaving the house. He then defined this approach as graded
exposure, stopped to ask if she had heard of this, then continued to explain that the process of
graded exposure involved team members taking her outside for a walk for five minutes and
then ten minutes, increasing the time slowly until she felt confident and comfortable.

This is a good example of posing a question and then exploring the answer with the patient to
create an intervention that can aid in their recovery. Graded exposure in this case is a slow

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process of building a patient’s confidence by accompanying them on walks in their
neighbourhood. Over successive walks, the distance and time increase until a suitable level of
comfort has been achieved. Occasionally they can be designed to improve the patient’s
confidence walking alone; by walking behind the patient, the team member can provide a sort
of safety net that the patient can use if they feel overwhelmed. Team members can also meet
patients a short distance from their home in a park or café, to increase confidence and simulate
real life scenarios. This is an intervention capable of (re)engaging the patient and
(re)familiarising them with their neighbourhood, but it takes time and is not a speedy process.
However, as the team member below commented, there is rarely enough time to carry out
these types of interventions.

Ahhh… these are things we used to do in abundance like when we first started
14 and a half years ago; but there doesn’t seem to be the time to do that. But if
it was the most necessary thing, yeah, we would do it – still do it, you know.

Time determines the interventions the team is capable of delivering. When I talked to team
members about time, I found a nostalgia around interventions that used to be done and a
distortion of their practice by not having enough time. Team members used to help clean a
patient’s flat if they were unable to do it themselves. This happened far less than before,23
despite the team often claiming a link between the state of the home and the state of the
mind. Staff reminisced about taking patients out to the movies on Christmas Eve because
“nobody else will be doing it”. Nostalgia has a particular relation with austerity often
reimagining the past and removing difficult truths like poverty or ill treatment to support
particular political goals (Hatherley, 2016); here the past is looked on fondly as a time when
there was time. Nostalgia was also called upon as a parable to young team members of what
could be done if only there was more time. In contrast, the team was now significantly busier
and under constant pressure to move people through the team, producing an increased focus
on process and throughput. A team member explained:

23
It only occurred a few times during my time with the team

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 I think, because now instead of the role being patient centred, so getting the
person completely well or as well as they can be and moving them on; it’s more
throughput, throughput, throughput. Its – I feel more and more it’s not about –
we’re not client centred anymore. We’re hospital bed centred. And then you
see loads of people, theoretically you’ve got that time frame to see a client, and
you’ve got 5 or 6 people. You can’t give that – where say a couple of years ago
you would have given that a whole hour to somebody, you can’t give an hour to
somebody. Because everyone wants to be visited between 10 and 11 and you’ve
got five clients, you can’t physically fit five clients, travelling everywhere, and
give people that quality of care that keeps them well.

The role of home treatment is slowly changing, while the need for practical interventions has
not changed. There is a slow attrition of time spent with clients and in terms of interventions.
The first casualties are those that are time intensive, those that act on the environment in
which a patient is living or those that involve the team assisting with the activities of daily
living. These were core aspects of home treatment and have a certain staying power as they
still occasionally are done, but the limit on these practical interventions affects the ability of
the team to engender lasting change. Unfortunately, as a team psychiatrist reiterated below,
there was not much that the team could do.

In some way, we haven’t set out to be that way, but in reality we just become
part of it. Because you know the ward needs to create beds, and the way to
create beds is for the home treatment team to take people on to create a bed.
And once the home treatment team is all clogged up, then we just need to
discharge them to community team. Sometimes patients are ready, sometimes
patients are not ready. So, you still push through the discharge. So passively,
we have been. We haven’t like, put our hands up and said this is what we’ll do;
it’s just being imposed on us.

The imposition of an altered role for home treatment that views them as a tool to create excess
capacity within acute wards has left teams short on time. A wide range of interventions
require an investment of time to deploy in an effective fashion. A team member who is short
on time might not be able to deliver even the simplest of interventions effectively. Just
handing a patient an information sheet on sleep hygiene is no guarantee that the information
contained within will be absorbed and applied by the patient. Delivering an intervention is
more than just handing out information.

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Delivering the Intervention
Working with a patient to deliver an intervention can seem deceptively simple. For example,
a DBT practitioner introduced the HTT to a basic set of principles/tools meant to help cope
with distress. These skills were referred to by the mnemonic TIPP which stood for
Temperature, Intense Exercise, Paced Breathing, and Paired Muscle Relaxation.
Temperature refers to dunking your head in cold or ice-cold water. The application of this in
the home was often, “when you feel like you want to cut yourself or you feel that urge coming
on, try dunking your head in cold or ice-cold water”. This was often met by laughter or
frustration on the part of the patient who felt like their distress was not being taken seriously
by the team.

The delivery of the intervention is crucial to making the patient feel like it will actually work.
Dunking one’s head in cold water can seem like a silly distraction or worse, a downplaying of
the severity of distress that is being experienced. A different approach might be to begin by
explaining that a bundle of nerves sits right above and between the eyes; the difference in
temperature can act as a shock to your system, resetting the affect or urge to cut24. When the
team was introduced to TIPP, they were not advised specifically how to apply this in the
field. What resulted was a sort of rough and ready application of this tool, that was often
dropped after repeated negative reactions/confrontations with the people they were treating.
How then should a team member go about successfully delivering an intervention?

During an interview, Jordan, a member of the HTT, walked me through the process of
helping a young man named Edward. Edward was experiencing depression with psychotic
features and had the delusional belief that if he stepped outside he would be shot. He was
terrified of going outside and the team decided behavioural activation was something that
would help lift his depression. Jordan began by explaining that although behavioural activation
appeared easy and theoretically straightforward, in practice it could be anything but.

24
This was the explanation given by the DBT practitioner.

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 For people that are incredibly low in their mood or incredibly anxious about
what has happened to them, beginning on that journey is so – it’s almost
impossible. And for somebody who is so totally depressed that they can’t get
out of bed, getting out of bed is hard, is so, so hard – just to do something very,
very, small; and we forget that, and if you forget that then you’re going to miss.
For the team, what they missed with Edward is actually, he really, really is
very, very scared about what might happen to him outside. And if you’re telling
him to go out there, into this place where he is incredibly scared and believes
something may happen to him, you have to really convince him that it’s worth
the risk and he has to believe that it’s worth the risk.

Jordan explained that they had to give Edward the tools to manage the way he felt when he
begins to go outside. He needed a skill that would help him manage the anxiety he
experienced in the transition to going outside, and the skill suggested was a breathing
technique. In the quote below, Jordan argued that they needed a convincing rationale for why
they were “equipping Edward with a deep breath”.

(…) I say well, go out there into this garden where something terrible is going to
happen to you and what I’m going to equip you with is a deep breath. I’m not
too sure I’d be convinced. So, you have to provide people with the rationale for
it. Why is it? What is it? Why is this helpful? So then you’re getting into kind
of the theoretical understanding of the fight or flight response, breathing being a
way of signaling to your mind and your body and your soul that actually, my
anxiety is higher than it needs to be and it’s ok to turn it down.

Jordan pointed out that just recommending that Edward breathe deeply before he went out
was not enough to make Edward believe that this would work for him. Explaining the
theoretical side as to why this approach might work provided a more convincing explanation
to Edward and helped to develop his confidence. The flight or fight response was a way of
understanding that his body’s response was out of the ordinary and opened it to intervention.
This created a framework where he could lower his emotional arousal through breathing
exercises, giving him a tool to help begin behavioural activation. Jordan went on to expand
upon the way this information or tool was delivered.

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 The delivery is like, so important. If I’m going along to somebody, I have to
believe it too, I have to believe it’s useful and it’ll work. If I don’t believe it’s
useful and it works then it’s like selling a rubbish product. You know, I may be
the best salesman and you might get some people that purchase it but other
people are just going to be like aehh…

When it comes to selling an intervention, telling a distressed and suicidal person that they
should dunk their head in cold water to temper the urge to cut is probably one of the more
difficult sales pitches. Creating a believable sales pitch for even the simplest of interventions
such as sleep hygiene is more difficult than it seems. Sleep hygiene was one of the top issues
that the team dealt with on a regular basis and yet, Jordan identified it as one of the most
poorly delivered. Something as simple as not using electronic devices an hour before bed was
not delivered in the same way the breathing technique was. Team members rarely mentioned
that the blue spectrum of light that these devices emitted interfered with the body’s ability to
produce melatonin which made one feel sleepy. This might have been followed up by
explaining that major electronics companies had started to address this with blue light filters
and nighttime modes. Sounding like you are interested in the idea and that it excites you
indicates to the person you are selling it to that there is a reason to get excited about it. Things
like tone of voice, intention, and drawing support from other sources can all be a part of
delivering an intervention skillfully. The importance of skillfully delivering an intervention is
amplified when that intervention is competing with something much easier that takes less time
and effort.

Team Member: If I go along to you and you’re in a –you need help, you need it
really badly because you’re on the edge, Yeah? It’s life or death. And I come
along and say, “See this, see this pill? Yeah? Take it, go to sleep.” And I go
home and I take it. See this piece of paper (feigns holding up a piece of paper),
Right? I want you to go away and I want you to practise; practise these skills
every day. That, over a period of time, will result in you sleeping better. What
do you think you’re going to choose?

Cameron: The pill.

Team Member: Of course. But actually, you know that the pill is problematic
and it doesn’t actually lead to the changes you want. Yeah, as a short-term
intervention it’s great for helping someone get to sleep. It’s great, and actually
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 combined with this stuff (feigns shaking a piece of paper), you’ve got a lovely
intervention. You know, but this (shakes paper) is of course about time, so
human nature, human nature – people don’t do it.

One takeaway from this discussion above has to do with his description of an intervention.
Jordan told me that the pill itself was not an intervention, it only became an intervention when
combined with psychological concepts, theory, or tools. The other important takeaway is that
this takes time; interventions are about an investment of time, both on the part of the patient
and the part of the service. As Jordan said, a pill cannot be by itself a crisis intervention—it
must be paired with other approaches, but a pill is often faster and takes less of an investment
of time.

Medications
One of the most important parts of the home visit was when medications were dispensed to
patients, because adherence to medication could often make the difference between relapse
and recovery. This process usually began in the same way. The medical chart and medication
was taken out of a bag, the chart was filled out, and the pills were dispensed. Occasionally
team members would list the medications and explain for the patient what each pill was for.
PRN medications were then offered if needed (in Latin, PRN translates to “pro re nata” or in
English “use when necessary” or “as and when needed”). PRN medications are generally
divided into sleep medications (i.e., Zopiclone, Zolpidem, or Promethazine which is also used
for its sedative effects) and sedatives (i.e., Lorazepam, Diazepam, Clonazepam). There are a
few other PRNs that are prescribed to deal with side effects from other medications, such as
Hyosine (scopolamine) for hypersalivating (drooling) caused by Clozapine, Senna for
constipation also caused by Clozapine, and other medicines used to treat various side effects
such as twitching, shaking, and sexual dysfunction, among others. Only small supplies of these
drugs are left with patients as most are considered to be highly addictive or habit forming.

Medications were prescribed as directed from the Maudsley Prescribing Guidelines (Taylor et al.,
2017), a book that gives the current cost of medications as well as their effects when mixed,
side effect profiles, and other information. There were numerous editions of the book spread

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around the HTT base and team members consulted them regularly before going out to visit
patients, particularly to note the potential signs of side effects. For instance, serotonin
syndrome was something nurses looked for in patients who had recently taken an overdose of
SSRI antidepressants (although they would be medically cleared before being admitted to the
team). In this case they asked questions about whether patients had a fever, agitation, rapid
heart rate, tremor, heavy or excessive sweating, dilated pupils, or diarrhea. These were also
symptoms they watched out for if the patient was just starting an SSRI antidepressant or
recovering from an overdose.

The use of specific medications were constantly changing and evolving with new evidence. A
consultant once remarked that for any one person to know all the information about even one
drug was too much: “it’s like knowing all the intricacies of the brain and neurotransmitter
reactions”. For instance, the usefulness of polypharmacy (the use of multiple psycho-
pharmaceuticals) has been criticised and is now seen as a practice to be avoided (Ito et al.,
2018). The same is true for prescribing doses at increasingly high levels, but actual prescribing
has lagged behind advice on best practice.

Home treatment has its own prescribing practice that has developed over time and works in
conjunction with its interventions. The HTT uses sedatives and sleeping pills to provide what
has been referred to as “chemical containment”. The idea of chemical containment is to help
stretch the impact that the team can have on a patient’s behaviour beyond the home visit. The
containment offered here is one that can help to produce a well-rested and calm patient. A
team member described this below.

I guess because we treat people in their home environment, we don’t have the
structure, the security of the ward and the staff 24 hours on hand to deal with
any situation. So really, at nighttime we need the patient to be sleeping, to be
settled, to not go out wandering in the middle of the road or screaming and
shouting and disturbing the family. So, there’s times I think we kind of really
positively encourage people to have a good night’s sleep, to comply with
medication and if they feel quite agitated or have difficulty sleeping, we really
are quite firm that they should take zopiclone or clonazepam or something to
help them settle down.
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As the team member mentioned, this could be a beneficial strategy for getting family members
some rest as well, keeping them happy and balancing their needs with the patient’s needs. It
could help to soothe concerns from the family and keep the patient at home. The sedatives
could be viewed as an adjunct to treatment in general, as they enabled the patient to be calm
enough to have a “meaningful conversation” with the team.

In some ways – in some ways you need the person to be of a certain level of
calmness, that you can have a meaningful conversation as well; and it’s just so
that in some way they can get through the day, not to be in a too distressed
state of mind and their family has some kind of hope. I mean, that’s very
important if the family feels – particularly if the patient lives with the family – if
they feel there’s no light at the end of the tunnel and they’ve been disturbed
day, and day, and day, twenty-four hours. I mean, we only go in for like ten
minutes to an hour tops, but the family are there forever, and you know they
need to be on board, they need to feel the treatment is working and they need
to have that hope.

The team member above made clear how important sedatives could be in preserving the
family home as an environment that was supportive. The use of medication in this way does
respond to the perception that the patient without sedation might get themselves into trouble
and hence it creates a sense of containment. However, as pointed out in the clinical literature,
it also potentially fosters a dependence on sedatives (Davies & Taylor, 2010). Sedatives can
be a critical adjunct for an acutely unwell patient if there is a lack of beds. However, it would
be concerning if this practice was relied on to hold acutely unwell patients in the home due to
pressure on inpatient beds. The team feared creating benzodiazepine addicts, especially since
patients were often left to taper the medication themselves. This fear of creating addicts and
its stringent communication to patients can make patients reluctant to take sedatives when
feeling in distress, defeating the purpose of their use in the first place. In some cases, they
avoided using benzodiazepines by prescribing low doses of an anti-psychotic (Quetiapine) that
has sedating effects, or an antihistamine (promethazine) which increases drowsiness. When
prescribing PRNs that could lead to a dependence, the psychiatrist always had to make a
risk/benefit calculation, and this often involved a discussion with the patient.

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Risk/Benefit, Diabetes, and Race in Prescribing
Psychiatrists on the team tried their best to balance the risks of taking a medication with the
benefits of that medication for the person being issued it. For example, some medications
might appear in breast milk at low doses but only cause mild sedation for the child, whereas
the benefit for the mother is considerable and so the benefits of avoiding psychosis outweighs
the risk. Psychiatry is pragmatic when it comes to medication. Psychiatric drugs are blunt
tools not magic bullets25 and therefore finding a drug that works for an individual can often be
a challenge, especially with the side effect profiles of these drugs. When a drug combination is
stumbled upon that works for a particular patient, it is usually maintained; the effectiveness in
reducing symptoms is foregrounded and a review of medication only occurs when the severe
or disruptive negative side effects become evident.

As I am not a psychiatrist, I cannot presume to comment on which drug combinations are

right, but I can show how this pragmatic prescribing washed over some important, and
occasionally concerning, aspects within patients’ lives. For an example, the drug Olanzapine is
an extensively used antipsychotic that has several properties that make its use particularly
appealing—but it also has several drawbacks. It promotes restful sleep and is quite sedating,
but often causes excessive weight gain through the development of cravings for sweet things
that can later turn into diabetes (Lord et al., 2017; Young et al., 2014).

I spoke to a long-time member of the team about its use. Dan and I chatted in a pool car on
the way to an appointment about the medications the team used. Dan brought up Olanzapine.
He told me that it was often too easily prescribed to people who had diabetes. He offered up
an example that I recalled from a few weeks earlier. It happened at an afternoon handover
when two junior doctors (psychiatrists) were present and the consultant was off for the day.
The nurses created a bit of a stir by claiming that an increase in Olanzapine would complicate
a patient’s diabetes, as the patient would have cravings to consume more sweets and their

25
With the possible exception of lithium and bipolar disorder.

141
metabolism would slow down. The junior doctors responded by dismissing the nurses’
concerns, instead ordering a corresponding increase in the patient’s insulin. Dan told me that
this was completely inappropriate—he stopped himself, and then said that it was bad practice
to prescribe something that slowed down the metabolism of someone who was suffering from
diabetes. I mentioned that I had seen similar patterns of prescribing for people who were
overweight or morbidly obese and Dan agreed with me that this was an issue with Olanzapine.
He cautioned me, holding up his hand while keeping the other on the wheel, telling me that
there was not much that could be done about either situation as the drug was very effective.
He told me that the system was now about how to get patients out of the inpatient unit as
quickly as possible: ‘it’s all about speed’26. He clapped his hand back onto the steering wheel.

Olanzapine is a favorite among the consultants on the wards because they know that its effects
are rapid, and people often become well enough to be discharged in short order. Dan
explained that it did not help to get consultants to stop and think about the other issues
surrounding prescribing Olanzapine because, when it came down to it, speed would win out.
With an exasperated tone, Dan told me that when they ‘kick them out they will give them
advice about diet and some psychoeducation but that’s about it’.

The difficulties with Olanzapine are not confined to the balance between the effectiveness
and speediness of response versus potential diabetes and weight gain, nor is it just a simple
equation. The first time I heard about this I sat with Tom and Miryam, both psychiatrists, in
the office where we often chatted about music, psychiatry, or other aspects of life before going
out on home visits. Miryam and I were talking about epigenetics and the cultural construction
of illness, and how my work might be dealing with this when Tom stated, “It’s kind of like
how you give 5mg of Olanzapine for a rich white person experiencing psychosis, and 15mg to a
poor black person. It’s cultural”. Miryam added somewhat sarcastically, “Yeah, 15mg depot”.

26
I use single quotes here as I was not able to write down verbatim what was said at the time.

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This statement and its matter of fact delivery by Tom and Miryam reveals something at play
within psychiatry and its prescribing habits. Is this an example of institutional racism? Studies
in America have shown that black patients are prescribed higher doses of anti-psychotics than
white patients (Diaz & De Leon, 2002; Kreyenbuhl et al., 2003; Taylor, 2004). However,
recent studies in the UK (of psychiatrists in SLaM) have revealed no difference in prescribing
habits between white and black patients (Connolly & Taylor, 2008; 2016; Connolly et al.,
2011). Yet, there remains an issue of “culture”; the alleged difference between 5mg and a 15mg
depot. I talked to Miryam about what they meant by culture; she insisted that there was
something to the experience of being poor in Lambeth that created this commonly known
fact.

Lambeth, Brixton, and South London in general have all been portrayed in the media, along
with the residents of these areas, as “threatening, aggressive and culturally ‘other’” (Howarth,
2002:238). This was present within the minds of team members, so much so that a number of
team members pointed out the various estates and places that had been featured in media
exposés on gangs, violence, and guns. Something about the cultural “other” in Lambeth
caused a belief among young psychiatrists that there was a significant difference in the way
that psychosis should be treated at the intersection of class and race.

Johnathan Metzl, in his excellent study on how schizophrenia became a mainly black and male
disease entitled The Protest Psychosis, documented how violence and aggression became part of
that diagnosis for a time (2009). Metzl’s larger argument in the book revealed how “anxieties
about racial difference shape diagnostic criteria, health-care policies, medical and popular
attitudes about mentally ill persons, the structures of treatment facilities, and, ultimately, the
conversations that take place there within” (2009:xi). Some of Metzl’s argument was reflected
in Tom’s later comments to me when I asked him about how prescribing was linked to
“culture”.

Yeah, I mean there’s the racial and economic factor in South London is huge,
and it’s easy on a general ward to feel like you’re a sort of extension of the
prison system, imprisoning young black men, or women I guess if you’re on a
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 woman’s ward; and I don’t think that dimension can be or should be ignored. I
like to think that people are managed objectively, but we know that people
have a heightened sensitivity to threat when they are confronted by a large
black man compared to a small white man, and to say that that threat is never
acted on or that perception of threat is never acted on would be naive so, that
probably filters into psychiatry as much as it filters into policing in other services
as well.

Tom’s answer here plays into the shadow condition of being “big, black and dangerous”
(Prins, 1993) which is not a local cultural condition; it is more likely a cultural condition of
psychiatry (Bhui & O'Hara, 2014; Fernando, 2017). The experience of psychiatric treatment
for racialised populations often feels as though it is an extension of the prison system and it
often mirrors the difficulties these populations face outside of the system, including “exclusion
from school, stop and search practices, overrepresentation in the criminal justice system”
(Keating, 2016:176). As a result, several authors have commented on how this builds a distrust
of the system that leads to later help-seeking and more acute presentations (Keating et al.,
2002; Robinson et al., 2011).

At the heart of this experience is coercion, which follows them every step of the way, often in
more punitive and restrictive forms of treatment (Bhui & O'Hara, 2014). The coercion does
not end outside of the ward once they are with HTTs. It was not unusual for decisions about
dosage and medications to be made at a clinical review or handover meeting, absent any input
from the patient. After these decisions were made, the psychiatrists sometimes had to be
reminded that the change needed to be explained to the patient and they needed to consent
to this change. Consent, in this case, was often step two, coming after the decision to change
medication had already been made. However, there were difficulties in making these
decisions; the team needed to know if a patient was taking their medication regularly as some
of the medications could be dangerous if doses were missed for long or even short periods.
This overarching process where the team prescribes, distributes, and adjusts medications, as
well as surveils compliance during home visits, is referred to as medication management.

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Medication Management
Medication management was part of the team’s standard care. The team removed any
medication from the patient that pertained to mental health as well as other medications if
there was a risk the person might take an overdose. This could make patients feel as though
they were not responsible or trustworthy enough
to hold onto their own medication. Sometimes,
in cases where taking the required medication
regime was confusing, it could be dispensed in
dosette boxes that had timed portions (figure 2).
These dosette boxes occasionally were held by
the team if the doses in them needed to be
Figure 2
adjusted or something else needed to be added or
subtracted.

Managing medication was partly justified by the fact that many of the medications the team
used needed to be slowly titrated up over time so as not to cause undesirable side effects and
to reach a specific level in the bloodstream. This also meant that if the patient stopped taking
their medication for a number of days and then took their regular dose, it could feel like “being
hit over the head with a hammer”. For this reason, team members watched patients closely to
confirm they were taking their medication, but this was rarely as easy as it sounds. They may
have taken the medication, swallowed it, and then gone to the washroom afterwards and
brought the medication back up or spit it out. This made it difficult to assess how a patient
responded to medication without blood tests to confirm levels. When someone failed to get
better, the team questioned the dose, the drug, and finally the trustworthiness of the patient
taking it. Subtle coercion could be used to ensure compliance with medications even when
this coercion was not backed by authority. In the end, unless the patient was under a
community treatment order or a Section 17 release, they were completely within their rights
to show team members the door.

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Exiting the Home and Ending the Visit
Each visit concluded with a walk to the front door, some pleasantries exchanged on the way
out, and the front door closing as one walked back to the vehicle or to the team base. One of
the reasons some nurses refused to take off their shoes during home visits was to enable them
to make a quick and timely exit if need be. This was the case with at least one patient who
started to do some suggestive things with a pen and frightened two nurses who bolted towards
the door, unlocked it, and ran down the stairs to their escape. They credited the fact that they
kept their shoes on with their ability to make such a quick escape. Most home visits did not
end with being chased out of a person’s home.

Patients could sometimes show people out of their home or cut off home visits in very
effective ways, often with staff realising only after they had left the flat that the patient had
curtailed and controlled the exit without them being able to intervene or even realise what was
happening. It was possible that during these moments of exiting the house, social relationships
of hospitality reasserted themselves on the doorstep. There were times that more personal and
less clinical questions would occur on the doorstep or the way to the doorstep. Comments
about family pictures on the wall, talk of plans for the weekend, and comments on home
decorations and even the garden were common. Once the team members had left the house, a
different process was begun that was intimately tied to the home visit, enough so that it
became the final stage of the home visit.

The walk or ride back to the team base was a time for sharing information and opinions about
the patient. It could also serve as an informal supervision session if something particularly
difficult had happened during the visit. Although my insight on the regular happenings of this
time is rather skewed towards my own experience, there is at least one source that suggested
that the same thing happened without my presence (Owen et al., 2014). Those who went out
alone had to wait for this until they returned to the team base.

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After the Visit: Home Treatment Staff After Care
On return to the team base, there were several duties that team members had. The most
formal and important was to return the medication and charts to their respective places and to
write up notes on the home visit. Perhaps equally important but less recognised was the formal
and informal supervision given and received by each team member. The work of the HTT
involved intensive emotional labour and a confrontation with distressing situations that could
wear on an individual’s own emotional state. It was clear to me that nurses, support workers,
and social workers all had difficult experiences in their work for the team, experiences that
could leave a lasting impression. I was involved in at least one of these experiences myself that
left a mark on everyone who was part of the altercation, including the AMHP and police. The
telling of these stories was sometimes meant as a cautionary tale and sometimes as a
therapeutic moment.

Many of the nurses started their careers on inpatient wards and occasionally told frightening
stories of time spent there. For example, when someone had an adverse reaction to
lorazepam27 and the staff member was so frightened by the violent reaction that they hid in a
broom closet. Some nurses reacted with a heightened startle reflex to random yelling or
screaming that came from outside, despite it being a regular occurrence. I was once talking to
a nurse who was fresh off the ward when we heard some screams and the nurse jumped onto a
chair to look out the window and then told me that everything was fine. A team member once
recounted a former police officer and family member who couldn’t understand why the team
members did not wear stab proof vests while out on home visits. The question that grew in my
mind was a similar one to the critique from the staff I explored above: Why is there not a
process of supervision for nurses that takes the same shape and function as supervision and
support for trainee psychiatrists or psychologists?

27
Benzodiazepines can sometimes have the opposite effect on individuals, creating an intense amount of
agitation, something a nurse once referred to as creating a “caged animal response”.

147
Trainee psychiatrists and psychiatrists that had made it through their training shared less
stories than the nurses did but still struggled with the effects of past experiences on their
practice. For example, Miryam and I were walking in the rain on our way to a home visit on
the opposite end of the borough. As we walked, Miryam told me that countertransference was
what could make people really good at their jobs; through countertransference you could pick
up on subtle things and work with the person that they originated from. Sometimes however,
she told me that she felt a bit like a sacrificial martyr for emotions, that she just sucked up or
absorbed all this stuff and did not know where to put it—a quite common complaint from
team members. I told her about medieval sin eaters who were paid to eat the sins of others to
absolve them of bad things they did, although these sin eaters were outcasts within society
because of their odd place between holy and unholy. I brought up a paper I was writing on my
own experiences of ill mental health and how I thought this had helped me in some way
become a better researcher.

As we got off the bus and crossed the street in the pouring rain among a busload of people, she
told me about how she became interested in psychiatry. Her mother had suffered from
psychosis and she had grown up in a world that her mother created for her after her father left
when she was seven years old. She was fully immersed in her mother’s delusions while living
with her and as she grew older became her mother’s carer. This was why she took up
psychiatry, though her progression into psychiatry was not as straight a line as it seemed. She
told me that, in a way, she was always treating her mother, which was why she struggled with
women afflicted by psychosis, because it brought her back to her childhood. Miryam was
aware that her past was present in encounters with patients who suffered from psychosis. She
took steps to remediate this by attending sessions with a psychotherapist on a regular basis.
Many team members also had some event in their past that propelled them into mental health
work. Miryam felt strongly that by working through these things in our past we became
stronger. Unfortunately, as one team member put it, supervision for nurses, social workers,
and support workers was often more “about helping people perform rather than being
therapeutic”.

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Within the HTT, there were two different, competing notions of what supervision was. The
consultant defined supervision as being about “practicing safely and effectively”, figuring out
how and what individual skills to develop, and giving team members a forum to discuss
difficult clinical problems, “which maybe are hard to manage individually where there is not
enough time to talk about them in other settings”. Other team members defined supervision as
aiding the individual in understanding and reflecting on difficult or distressing situations, how
they might approach those situations in the future, and how their own experiences and actions
might have contributed to that situation.

There was a formal structure within the team that provided supervision by senior members of
the team on a regular basis. Alongside that formal structure, there was an informal practice
where team members supported each other simply by listening and lending advice on practice
or difficult situations. There was also a staff support group, led by an outside moderator, that
met once a week at the same time—though many team members opted out of this. In addition
to this, the team provided a supervisory presence through handovers and clinical review,
where team members felt free to point out what might have been bad practice or how
something might be have been done better. These four streams of supervision combined to
produce a rough framework for dealing with the difficult emotional nature of this work, as well
as fostering the development of practice and, to lesser extent, providing a disciplinary
function.

The difficulty with this supervision process was that it often did not match the needs of the
situation. Throughout my time at the team, formal one-to-one supervision was officially
provided once a month for each team member, although I heard from many team members
that it was more like once every three months. Several team members put forward critiques of
not only the supervision process but also the way that mental health services looked after and
developed their own practitioners. One team member brought up the fact that psychologists
and therapists “place great stock in the supervision process as much about coping with clients
as it is about gaining self-knowledge of what one brings to somebody else”. The implication
here was that nurses, support workers, and social workers often were not given the supervision

149
necessary to develop an awareness of the way their personal history might affect their
approach to a situation. For example, the team member brought up the assessment of risk.

The assessment of risk is inevitably about your own development as an

individual and how you perceive risk, or the necessity to take risks, or the need
to be risk averse from your childhood. So, you’re going to project all sorts of
stuff from yourself into the patient and become anxious about it. If, for
example, you know a piece of risk-taking in the past has gone exceptionally
wrong, or your view of how to take therapeutic risks on behalf of your patient
for their benefit, you’re going to be managing yourself rather than the patient;
and it’s those sorts of things that really need to be raised in supervision.

What this team member explained was that the way members of the team perceived and
operated with risk was based on their own personal and developmental experience with risk.
The inability to come to terms with what the practitioner was bringing to the interaction could
impact their decision-making. Ideally a group supervision session might have addressed these
issues, but these sessions were often unable to deal seriously or effectively with personal issues
and distressing elements of practice. A team member elaborated on this below.

You know, since practising in psychiatry, I’ve never known a group supervision
group to evolve where people are sufficiently comfortable to be – to talk about
those things. It’s a bit of an indictment really, isn’t it? Because the one thing we
would need to address is our own, our own fault lines, when it comes to
managing stressors that are thrown at us. What is it that pushes my buttons?
Does anybody know? Does anybody know? I doubt it. They might know
through lived experience, and they might recoil when they see that I get a bit
huffy or a bit terse or whatever it might be; but it’s never then discussed
afterwards, and I think that is really a big problem. Particularly if we are
claiming to be psychiatric practitioners with psychological sensitivity and we’re
not able to necessarily enact that between ourselves.

This team member laid out a very different role for supervision from the consultant. This
version would still encompass professional growth and development of practice but would
revolve around exploring what the individual brought to the encounter with the patient. This
was a type of supervision that was crucial to the development and training of these
psychiatrists and psychotherapists but was surprisingly not on offer to team members. One of

150
the more concerning aspects of this for the health of HTT members was that, however skilled
they were at carrying out emotional labour in patients’ homes, they somehow lacked the
ability to turn that practice on themselves and other members of the team. This inability was
quite a striking indictment, especially when individuals within the team became unwell or
struggled with their own mental health.

Discussion
The difficulty inherent in helping people perform, as we have seen, is that it often involves an
almost equal amount of personal skill, patience, and most importantly time. The HTT’s
effectiveness is mediated by time; the more time that they have to deploy interventions
directed at long standing issues, the greater effect they can have on their clientele. It is also
about space. It is about carving out a space of treatment where psychiatric authority can take
hold, about constructing futures for patients collectively and selling the interventions to get
from present to future. Space also plays a role on the team’s ability to treat patients; it takes
time to traverse the distance from one visit to the next, and the more patients they have, the
more time is spent travelling. When the team is busy, it faces a time-space compression that
accelerates the speed of the team and brings with it the use of shortcuts like the “naught to
ten” scale or discussing the level of insulin alongside the levels of olanzapine. Shortcuts have a
focus on the immediate, but they fail to make up for the loss of information, or the
complication of underlying comorbidities. In the next chapter, I will consider how home
treatment has become a central part of the move towards efficiency, accelerated patient flow,
and lowering the cost of care in a situation of austerity.

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Chapter 7: Managing a Political Economy of Care

Historic models of service delivery are unsustainable in the face of financial challenge, societal
change and demographic shift (SLaM, 2014c:3)

This chapter will begin by exploring the ways in which the Trust has developed a specific
political economy of care that values cost savings above patient experience. I will show how
the Trust manages the HTT in a way that saves beds and counts on the team to maintain
quality care despite the pressure placed upon them. Following this, I will explore how the
Trust embarked on a process of service redesign and consultation with the HTT that was
driven by a political economy of care. The consultation reveals a tension between process
work and caring work at the centre of this political economy of care. I then shift to the HTT
and examine how they cope with these changes. I begin by looking at why they feel
overwhelmed. I follow this by looking at whether thresholds for discharge have changed and
how difficult it can be to keep these from changing. Finally, I look at some of the
consequences of the consultation and how these actually reveal a data-based solution to save
money that has been overlooked by this political economy of care.

Home Treatment, the Trust, and a Political Economy of Care

The HTT is the nexus of the mental health service. Every patient in crisis is assessed by home
treatment and then either taken on as a patient or moved on to an inpatient bed. Home
treatment also receives early discharges from inpatient wards. As such, the HTT is positioned
as the gatekeeper between inpatient wards and every CMHT, Psychiatric Liaison Service, or
other referring service/entity (neurology department, etc.). The present service ecology
resembles a circuit (Figure 3). One full institutional circuit for a patient could be, for example,
admission to the Triage ward via the Psychiatric Liaison Service (after being gatekept by
HTT); spend four days on Triage, then be discharged early to the HTT; receive HTT
treatment for four weeks following which they are discharged to a CMHT; the CMHT then

152
keeps them for 12 weeks
after which they are
discharged to the GP. As
becomes apparent, the
HTT is positioned in the
middle of the circuit, which
exposes them to pressure
from the inpatient wards in
the form of early discharges,
Figure 3
pressure from the CMHT in
the form of patients going into crisis and being referred, and pressure from the Psychiatric
Liaison admitting patients to the team.

Pressure flows through this system, challenging the ability of home treatment and other
services to keep up. The flexibility of the HTT, found in the loose constraints on its practice
and mobile services, allows it to bend with the pressure but also to fill a role within the system.
That role is based on its historic ability to reduce the usage of beds, which, in a system under
pressure that is tightly resourced, becomes one of its primary assignments. The Trust deploys
a strategy that utilises the services (including home treatment) within this loop to deal with
excess demand for beds and services, while at the same time attempting to significantly reduce
the cost of care. In other words, the Trust’s strategy to manage resource scarcity is essentially
a political economy of care that is structured around delivering the most cost-efficient service.

Cost efficiency can be thought of as the shortest amount of time spent with services or the
least amount of money spent per patient, or both. What this political economy of care
produces is not an efficient service, rather an efficient pass through the loop, from Acute ward
to GP, and back again. The view the Trust takes is based on a time-frame that does not
account for relapses and multiple trips through the loop. Therefore accelerating the movement
of patients through this loop reduces the cost per patient. An alternative way to measure cost
efficiency would need a much larger time frame, stretching across the life-course of the

153
patient, bringing the immediate and long-term needs of the patient to the foreground and
pushing potential costs to the local mental health system into the background, amortising the
upfront treatment and investment to prevent relapses across the life-course of the individual.
The tension between these two approaches, a tension that exists across this chapter, is
between process and care, system and patient, speed and quality.

This short-term time frame puts pressure on the HTT, forcing the team into taking an active
role in reducing the costs to the system. The Trust, I was told, believed any level of beds
would be utilised to 100 percent capacity because the threshold for admission would go down
if there were spare beds available. This perspective views any level of beds as leading to an
eventual crisis and thus acts as a justification for the artificial pressure applied in all situations
on the use of finite resources like beds. The pressure on the HTT came through daily
conference calls with senior managers that focused on freeing up beds, pushing early
discharges ahead of other referrals, and trying to avoid “delayed discharges” (a benchmark for
performance). In an interview with the Clinical Service Lead (CSL) for the team, he
described the way the Trust was managing the cost of care.

That’s what it’s down to: the cost price attached to one person being in an
inpatient bed for a day is X amount of pounds. So, if you can bring off, if you
can get three patients off the Ward, three or four days, a week early that’s a
quantifiable amount of cash. And I’ll tell you what it means, it does come down
to that. A day here, a day there, overall, over the weeks and months which
hopefully adds up to a saving, really, and I think that’s the driver. I mean you
could say it’s quite a little bit, it’s quite reactive you know. I mean there’s
pressure on the services that’s costing the Trust money, so that’s where the sort
of focus goes.

The focus here is on the ability of the HTT to micromanage time spent on the ward by
patients. The pressure threatens to put the needs of the system above those of the patient—it
is the HTT’s responsibility to worry about whether the right clinical decisions are being made,
not the Trust’s. This is only one in a long line of adjustments the Trust made to streamline the
service and to deal with one of the most costly practices of the local mental health system,

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out-of-area placements: the practice of paying to place patients in inpatient wards across the
country due to a lack of beds within the local system (Bloom, 2015).

One of the early efforts at reducing this practice was the creation of a new type of inpatient
ward, the Triage ward, that was focused on rapidly assessing patients, starting treatment, and
moving them on to long-term, female/male wards or back home to be worked with by
CMHTs or home treatment (Inglis & Baggaley, 2005; Williams et al., 2018). A psychiatrist
who worked on the ward explained:

The goal of triage is to move people on; and as soon as they come in you’re
thinking about moving people on, so you don’t really need to feel pressure
because you don’t need any extra source of pressure, because that’s your
function as a triage doctor.

Here the assumption is made that the inpatient ward will make the correct decisions for the
patient in as accelerated a manner as possible. The burden of the quality of care is placed
squarely on the psychiatrists who are being tracked and assessed by performance indicators
based on how fast they can move people on to other teams. The Triage ward was a fixture
during my study, but was always under threat as it failed to make an impact on bed use.

The Triage ward system was another attempt to create bed capacity without commissioning
more actual beds, and arguably came at a direct cost to the patient. However, not all of the
Trust’s attempts to reduce the use of beds came at a cost to the patient. When I first started
my fieldwork, the Trust had finished a reorganisation of the mental health system that focused
the HTT on preventing the use of inpatient beds by taking on patients who were at risk of a
crisis or deteriorating into a crisis. This “Adult Mental Health (AMH) model” hoped to use
the HTT to intervene before the patient escalated to the point where hospitalisation was
necessary. By deploying HTT staff to sit in on CMHT meetings, providing better
communication and continuity of care, they sought to send patients to home treatment at the
first sign of crisis. However, this approach failed to provide the necessary effect it was created

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to have. I now turn to the most recent effort and extensive redesign of services that the Trust
embarked on during my time with the team.

Consultation/ Consolidation

We’re considered as the golden key to solving the Trust’s problem with not having sufficient
beds, because even if there is a bed for someone to go to, no matter what the issues are, then
home treatment can take them

– Team member

This redesign of the Trust’s acute services followed their overall five-year strategic goal which
was to “move the centre of treatment further into the home” (SLaM, 2014c). From the very
beginning of the process, it was clear that a complete reorganisation of the system and
pathway was out of the question. Lacking the funds to do this, the Trust instead visited other
HTTs and Trusts and attempted to take elements of those services and apply them to their
teams in a piecemeal fashion, with the assumption that this would provide a net improvement.

At the beginning of the redesign the Trust contacted the senior leaders of all the HTTs (in the
Trust) in order to develop working groups on various issues that were staffed by clinical
service leads, psychiatrists, as well as the rumoured involvement of a US-based consulting
company. The Trust began its restructuring by creating a new collectively managed group of
“acute” services that included Home Treatment and every inpatient ward but no CMHTs or
Psychiatric Liaison Services. A new senior manager was brought in to head this group and the
service redesign, a psychotherapist with no experience in home treatment.

When the decisions were finally made as to the potential changes, they were presented to the
team through a document entitled Home Treatment –The Way Forward. This was followed by a
period of time for team members to respond and submit comments and questions. After
adjusting for these and releasing a second document, the changes listed in the consultation

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were enacted. I will go through this process step by step and detail aspects of it that contribute
to a greater picture of the political economy of care within the Trust and what was expected
of home treatment in service of this economy.

Early on, the Trust showed the seriousness with which they would approach this redesign by
discontinuing the use of out-of-area placements in private beds. The Trust did have to
temporarily reverse this decision a few weeks later after an extremely busy period, but then
reverted back to the policy of not using private beds. This decision also involved disbanding
the special team28 that managed and retrieved patients in private wards across the country,
which gave a finality to the decision to stop using private beds. To cope with this, they
increased their use of home treatment teams by having them concentrate on early discharges
to clear space on the wards. The Trust intensified their management of the HTT and
inpatient wards, trying to squeeze out more and more bed days. This was met with quite a bit
of disbelief from team members as they could not imagine a scenario whereby an individual in
crisis was kept out of a hospital bed merely because the Trust did not want to use one. Team
members thought that the risk was unfairly (in some circumstances) placed on home treatment
teams as they would have to hold onto riskier patients for longer. This is made clear in the
following example which shows the pattern of thinking that the Trust had deployed to deal
with private beds.

This example begins with a call coming into the team around 8pm to screen a patient for
admission to the HTT from a hospital north of the Thames in a different borough. The team
member referred them to the proper protocol for doing this. The hospital called back and
requested an informal admission for the patient, as the patient was actively suicidal and had
been participating in risky and vulnerable behaviours. The team member outlined:

So I said, “Ok then, I need to speak to the on-call medical manager (who is
normally a consultant) and go through and request for a bed”. So I called the

28
This special team was created because there was no financial incentive for private wards to discharge patients
when they had recovered, so the Trust had to monitor them and send someone to assess for discharge.

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 doctor, the doctor said that “I don’t believe it, I don’t think she needs
admission. The patient has a choice, and get the patient sent over to us and let
a SpR [Specialist Registrar Psychiatrist] assess”. So the SpR is normally a little
bit more senior doctor and so this has never ever happened, well nearly never,
ever, ever happened. You don’t send people from A&E to A&E, and you deal
with it there and then. Bear in mind their doctor assessed, their PLN
[Psychiatric Liaison Nurse] assessed as well. So anyway, I was told to pass on
the message. They were decent enough not to shoot the messenger. So
anyway, the patient arrived at a hospital in our Trust, the PLN assessed, still
going for admission and the SpR arrived at 2am and assessed for admission. So,
10 o’clock this morning an email comes through from the senior bed manager
who says “home treatment team, I’ve been trying to get a hold of you. You
need to go to a hospital in the Trust to reassess this patient”.

So which part of this is for the patient’s interest? Is to enhance quality of care?
And then a senior team member went to assess, outcome is: still not taken on,
go for admission.

The above incident was certainly exceptional, but it also marks how far the management was
willing to go to enforce their new policy of not using private beds. It shows the absolute
importance given to managing beds and the amount of resources they were willing to bring to
bear to do this. The consultation with the team began without many of the team members
knowing about it in the form of negotiations between the Trust and union reps to change the
job descriptions of nearly every nurse, social worker, and support worker in the HTT. The
first notification many of the team members received of the consultation came in the form of
an official document and a meeting with the team.

Consultation Document

The Trust, like many mental health organisations, have a need to address the increasing
demands for mental health provision whilst working in an environment that demands
improved values for money with less income generated from traditional sources.

– Opening line of the consultation document

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The first line of Home Treatment–A Way Forward makes the Trust’s position clear—these
changes were being made to cope with cuts and “home treatment teams (HTT) play a central
role in supporting the Trust’s objective in reducing ‘out of area’ placements”. The consultation
would be about saving money and beds, not about quality of care or value to the patient. Yet,
the presentation of these changes to the HTTs would pay lip service to these changes being
made in the interests of the patient. The four categories/headings for the rationale behind the
changes were listed as: value to the patient, value for money, quality, and national guidance.
All four of these headings appeared in the document and had various supporting points listed
below the headings. I will show that many of these points are counter to the Trust’s
supposition that these were beneficial to the patient.

Under the heading “Value to the Patient”, there are three important points that the Trust raised.
The first is the statement, “Home Treatment is overlooked in favour of an admission despite it
being the less restrictive treatment option for patients”. What is referred to here is the
Approved Mental Health Professional’s (AMHP) legal duty to consider the least restrictive
alternative to detention. The Trust seemed to be claiming that hospital treatment was being
favoured over home treatment despite the fact that home treatment was less restrictive.
However, it is plain that the underlying reason for promoting home treatment rather than
hospitalisation as a first option was to lower bed usage. There are several difficulties with the
argument that HTTs should always be considered the least restrictive. Home treatment is
often still restrictive in that people are regularly invading the privacy of the patient and
because there is often an implicit or explicit threat of hospitalisation if home treatment fails.
Further, the place and quality of detention are part of the calculation that goes into the
decision to detain someone, so, the AMHP must consider whether the short amount of time
the patient will be admitted will provide a net benefit to them and whether the chaotic
environment in the ward will allow for a substantial improvement. The AMHP must also take
into account the living arrangements when it comes to staying in the home, considering
whether a patient with no gas and electric can engage with the HTT. The way that the Trust
characterised home treatment as self-evidently less restrictive than hospitalisation does not
reflect these issues or the complexity of the decision being made, which must be based on the

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value of the intervention to the patient. To pressure AMHPs to utilise home treatment as the
least restrictive option or to consistently opt for an agreement with patients that they must
engage with home treatment or be subject to hospitalisation is not in accordance with the spirit
of the law nor in the best interests of the patient.

In the section of the document on “Value to the Patient”, the Trust insisted that there was an
inability to properly and thoroughly track “the progress of patients across the whole treatment
system, to ensure optimal management of cases and flow through the system”. They also
claimed that “understanding the ‘value’ of home treatment to patients is made impossible
without the collection of patient outcome data”. Both statements are only loosely related to
value for the patient—they are focused on producing more data on the way patients move
through the system in hopes that they will be able to adjust the system in small ways to
produce efficiencies and save the Trust money and bed days. “Flow through the system”
means that the movement between teams will be swifter. In fact, the available data was poor
and inconsistent, yet data quality was never addressed. In meetings that I attended, senior
managers talked about data as if it could produce excess capacity in the system with absolute
certainty, if only they could collect enough of it.

For example, I attended a meeting held on the hospital grounds in a long boardroom that
featured pictures of the original Victorian hospital. The consultant Aubrey and the CSL from
the HTT were skeptical of the ability to use data to solve the Trust’s problems. During the
meeting, Aubrey pointed out that the problem with the lack of beds would not be solved
without a significant focus on “frequent flyers” and the specific issues that were keeping them
unwell or causing them to relapse repeatedly. Aubrey underlined the fact that quality
improvement philosophy was not about trying to cut bed use but about re-shaping practice
which, in his opinion, was not the focus necessary to alleviate the bed crisis. The senior
managers’ response was to claim that by profiling the patients who had been with the HTT,
they could identify who to send to the HTT right away (from acute wards); they could “use
data to help clinical conversations”. This is reminiscent of the argument about Measurement
Based Care (MBC) described by John Fortney et al. as entailing “the systematic

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administration of symptom rating scales and use of the results to drive clinical decision making
at the level of the individual patient” (2016:180)29. By the end of the meeting, it was clear that,
despite the hundreds of years of experience present in the room, the senior managers were
unrealistically confident about the capacity of data to inform practice.

Under the heading “Value for Money”, the Trust crafted an argument that HTTs had boosted
funding and the result from that funding was that the “operating model has remained the same
with no recognizable advantages to patients”. This suggests that the current model must
change for the benefit of the patient. If you were to ask team members how to do this, they
would have suggested adding more time for home visits and supervision. The Trust made a
different argument from the team members in the section below, entitled “Quality”.

This argument was that the teams had not met the criteria for HTTs set by the Royal College
of Psychiatrists for accreditation (2015) or the fidelity scale from the CORE study. They went
on to argue that performance evaluation was difficult as there was “no clear agreement about
what is important to measure”. The team I was with was already being performance-managed
to save bed days, which taken into consideration with the above leads me to argue that rather
than this having something to do with the quality of patient care, the Trust was claiming that
these teams were not achieving a significant enough reduction of beds and cost savings. The
CORE fidelity criteria were created with the explicit purpose of solving the debate between
psychiatrists on whether HTTs reduce the use of beds, which stemmed from the debate about
HTTs that was headed by Sonia Johnson, the lead researcher developing the CORE fidelity
criteria (Johnson, 2011; 2018; Lloyd-Evans et al., 2017; Tyrer, 2011; 2013a). Adhering to the
CORE fidelity criteria is as much about achieving a reduction in the use of beds as it is about
best practice or quality service. Whether HTTs can achieve lower bed usage remains
contentious, but the Trust’s argument that the teams should adhere to these criteria and be
performance-managed was clearly about managing bed stock and saving money.

29
This is currently the most popular article in Psychiatric Services.

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All of the headings explored above reveal the political economy of care to be guiding the
redesign of home treatment and other acute services. Despite the language in the document
hinting towards it being exploratory, there are clear conclusions being drawn which are
consistent with the way the team was being managed. Where does this leave the caring
aspects, the unquantifiable aspects of home treatment that have been detailed in the anatomy
of a home visit? Caring, patient welfare, or patient-first approaches were absent from the
stated principles that were used to design these changes. Instead, many of the key principles
read as though they were taken from a business textbook. One of these pointed to a new “hub
and spoke” model of service, which was implemented in the new Acute Referral Centre
(ARC).

ARC and Central Place of Safety

One of the largest parts of the consultation involved the creation of a hub or, as it would be
known, the ARC with the spokes being the HTTs and inpatient wards. The ARC took a
rotating crew of several members of each trust HTT and used them in a central place of
assessment. The ARC took over the majority of gatekeeping duties from all HTTs, allocating
assessments to each of the HTTs based on their catchment area. The ARC ran 24 hours, had
independent management, and was placed in a central location for all of the boroughs. It is
reasonable to believe that this central location was chosen for its proximity to the Trust’s re-
provisioning of its Place of Safety or 136 Suites.

The Trust had been assessing its ability to provide a place of safety or a 136 suite in each
borough and had decided to build a new facility in a central place for all the boroughs they
served. A 136 suite allowed police to take a person in crisis from a public place and bring them
to the suite where they could be assessed by mental health professionals and then moved into
the system to an inpatient ward, a CMHT, or the home treatment team (the HTT would
assess separately). Part of the reasoning behind opening a single “central place of safety” by
the Trust was to provide a dedicated service with dedicated staff members; another was that
the places of safety spread throughout the borough were often full. In 2013-2014, the Trust

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had 833 presentations at places of safety, the most in London.30 The very public problem of
police having to hold on to people in crisis (Campbell, 2016; Dodd, 2016; Travis, 2014)
spurred them to build a larger unit.

The unit was built in an empty space set back from the main road and down a short, side
access road behind the main hospital area. This area had (ironically) at one time housed the
24-hour walk-in psychiatric emergency clinic that was closed due to funding cuts under
significant protests from service users and members of parliament due. Many of the employees
of the Trust were unhappy about the closure of the emergency clinic and when they heard
about the new central place of safety being built in the exact same spot, they were frustrated
by the fact that the clinic had been closed in the first place.

When I visited the CPOS for a tour before it opened, I realised that it was directly beside the
new ARC where all HTT assessments would happen and beside the bed management team.
While I was at the CPOS, a trust manager chatted with me about how it was likely that an
AMHP would be stationed at the CPOS and the HTT would eventually assess patients there
as well. The ARC and bed management would run right next to the CPOS which would
potentially have an AMHP either on-call or on duty 24/7. This set up would allow for the
assessment of any individuals dropped off by the police at CPOS by an AMHP, who would,
in combination with other health professionals, decide if the individual was suitable for
admission. If the individual was not suitable for admission, then a referral would be made to
the HTT. The ARC would receive the referral and would either charge one of the teams with
making the assessment or they would go and complete the assessment themselves in the
CPOS. The idea here was to be able to divert individuals who would normally end up on an
inpatient ward to HTTs and thereby save beds for those who were the most unwell.

This constituted a potentially risky expansion of the role of the HTT. The reason HTTs were
not assessing people in 136 suites was because of a lack of information about the patients’ living

30
Trust Document on CPOS

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situations. With less time to work with patients, taking on a patient who might not have the
basic necessities to live in their home or who may be turned away from that home was too
difficult and timely a task for the HTT to deal with. The way the Trust saw it, HTTs could
have a chance to take on patients who would regularly be sectioned by the AMHPs and end
up taking a bed. This was where the Trust saw unmet demand for HTT and it also fit into the
argument that the HTT should always be the least restrictive option, meaning that HTT
would take the majority of 136 patients, who would then either get better or fail and take a
bed. The anxieties around the ARC and the potential changes to the service were on display
throughout the consultation process and during the changes.

The Consultation Meeting and the Response

The consultation process was headlined by an early morning presentation from Joan, the
senior manager in charge of HTTs and the psychiatrist who was co-leading the service
redesign. Joan made clear that the discussion was about the Trust “managing acute treatment
and bed stock and that the HTT plays a part in this”. She added that “often home treatment
is seen as a team that can solve all the problems, but [she’s] learnt herself, that it is only one
part of managing these issues”. The lead psychiatrist then stood up, introduced himself, and
described the new pathway for home treatment as “collaborating with the wards more, while
providing high quality and efficient care”. Although the ARC was mentioned, no reference was
made to the CPOS or the fact that the ARC would be inside the bed management office. The
consultation meeting made clear the goal of the Trust which was to use the HTTs to manage
beds and acute treatment.

After the presentation, the floor was opened to questions.31 The discussion was heated with
concerns expressed that the team would become de facto bed managers for the Trust. This
could violate their code of ethics, as bed managers ensured that the Trust was saving money
whereas nurses ensured that the patient was being cared for. Aubrey stepped in and brought

31
The team also passionately defended their compressed shift patterns, claiming they both allowed for a better
quality of life and created continuity on shift.

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the meeting to a close by stating that “there will be more capacity to address sickness” but the
“trust is going bankrupt, there is a bed crisis and this is the strategy to mitigate the effects of
that crisis”.

A week later the team met to discuss the consultation and consider how they would respond
to it. Many of the team members felt that the response was a moot point as the decisions on
high had already been made and would stand regardless. The team sent in both individual and
group written responses, which were then combined with other teams’ responses and
answered in a final consultation document, once again entitled The Way Forward.

The Consultation Feedback Report

The National Health Service as an entity is under unprecedented financial burden at a time
when demand is ever increasing. The Trust is not immune to both the financial and demand
pressures and like many mental health organisations have a continuous need to challenge
established practices in order to “move with the times” and evolve as an organisation. Home
Treatment Teams (HTT) are key in supporting the Trust’s objective in reducing “out of area”
placements whilst also playing a central role in the overall acute care pathway.

– Final Consultation Document

The final consultation document began with the above statement. The Trust saw itself as a
financially strained entity that needed to “challenge practices” to “move with the times”. This
statement followed the political economy of care that existed within the Trust that I have
been carefully documenting in this chapter. The responses by the HTTs detailed in this
document for the most part created a dichotomy between the needs of the Trust and those of
the patient, with the side of the patient and quality of care being defended by the HTT staff
in their comments. The Trust made an effort to respond to each of the comments levied by
the HTTs, but dodged some of the tougher questions and ignored others altogether.

The document addressed “value to the patient”; however it stated that the changes would
“improve better[sic] patient flow and support HTT to assess the right patients at the right

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time”. None of this actually pertains to value for the patient, as moving through the system
swiftly is not necessarily good for patients or even what patients want, nor was the Trust’s
decision that staff should make at least four visits per shift, a goal which was possible, but cut
the time for the actual visits down to a minimum. The teams underscored this by reminding
the Trust that “rushed and poor quality visits is the most consistent complaint from patients
about HTT across the UK”. One comment took it further, pointing out:

The consultation paper appears quite prescriptive in stating how many visits
staff should do. Numbers have context and a rigid enforcement of tick boxes
and performance criteria has risks. The Francis report into mid-Staffordshire
hospital found “A culture focused on doing the system’s business—not that of
the patients” a contributory factor in patient death

The above comment provides a different way of looking at the political economy of care. The
political economy of care is, as Francis would described it (2013), the “system’s business”. The
bulk of the consultation had been about developing a system that managed the costs
associated with inpatient care by efficiently moving people out of the inpatient wards and into
home treatment. In the final document, emphasis was placed on patient flow and ensuring that
staff were making at least four visits a day. Challenging established practices in this case was
more about a cost savings then quality patient care. Even worse, there was little to no
evidence to back up these challenges to practice, making it a potentially reckless pursuit. As
one comment pointed out, these changes “come with significant risk to service users and staff
as the change from established working practices to new untested procedures increases the
risk of system and communication failure”. This was also a warning that the King’s Fund
produced in their report on service redesign (Gilburt, Edward et al., 2014).

What the document and process did systematically produce were new areas where pressure
could be applied to the HTTs in order to produce further cost savings, even going as far as to
remove previous checks and balances on pressure. For example, the consultation removed
referral forms which were originally developed to keep bed managers from continually
referring the same patient until a staff member agreed to the admission. These were safeguards
created to prevent inappropriate referrals, made in the interest of the Trust clearing space
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rather than the patient. One comment addressed the pressure already in the system by
pointing out that the move to a “one in, one out” system was a significant change “away from
person centred crisis care [and towards] managing the borough’s bed crisis”. Included in their
comment was their experience of a significant rise in the “number of patients with complex
risk presentations”. The response from the senior managers (below) was to dodge this question
entirely by sticking only to the actual consultation document and ignoring the recent policy
changes that had happened but may not have been part of this consultation.

Home Treatment Teams are central to the acute system and support the Trust
to manage their bed stock. Going forward it is expected that HTT will work
hand in glove with wards, community and bed management. Person centred
crisis care should not be considered in isolation and forms part of managing beds
in so much as ensuring patients have access to beds when they need one.

There is no information provided in the consultation that suggests increasing

numbers of complex risk presentations and fit with one in and one out
expectation.

This response is a microcosm of how the Trust viewed the treatment of patients through the
lens of the political economy of care. Person centred care for the Trust meant that beds must
be available to treat patients; accelerating the system and finding new ways to increase the
capacity within the system ultimately would allow for beds to be available when they were
needed—thus the system was patient centred. This is a pessimistic viewpoint that views the
mental health care system as not a vehicle for recovery but a series of inputs and outputs,
margins and columns, names and numbers. Here treatment is whatever the system can offer
based on a cost per unit that does not exceed x. The reliance is on the teams to deliver quality
care while remaining within the appropriate costs and margins. The Trust refused the premise
that patient centred care began with the patient; rather they saw it as beginning with the
existence of the treatment apparatus. Throughout the consultation process, the Trust had
defined what was up for debate and what was not. The second part of the above quote shows
that they were able to deny aspects pertaining to the reality of home treatment, despite their
existence, merely because they were inconvenient truths.

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The comments presented on the consultation that appeared and were addressed in this final
document revealed the extent to which HTT practitioners took seriously the care of their
clients and their ability to deliver a service that worked for their clients. The difficulty with
this was that the teams must work to find a new balance between doing the business of the
system and that of the patients—a balance between process-based work and care-based
work—and in doing so they must also address some hard truths about patient focused care.

Managing Pressure, Practice, and Resource Scarcity in Home Treatment

What is the plan about, getting rid of them [the patient]? Because no, it’s not about getting
somebody well, it’s about getting them well enough so that they don’t need home treatment
team. That’s why we have a lot of revolving door people, I think, because there’s pressure,
pressure, pressure. So, we’re just like, the second, were like, kind of like a circle. Hospital,
home treatment team, community team, GP; and it’s GP, Hospital, and kind of a circle and
we’re just one clink in this circle and we’re like “all right, we’ll go and get that person just well
enough so they can go back to the community team”. Ready, out of crisis – but not out of crisis
enough that they are ready to go to the community team, but they are, because you’ve got 5
other people who need to be getting out of a bed.

– Team Member

The above quote describes the

difficulty that the HTT had
adapting to the demands of the
new political economy of care
that the Trust had developed.
The team was being actively
performance -managed to save
bed days or even fractions of bed
days which provided an overall Figure 4

cost savings for the Trust. This practice involved increasing the speed with which patients
moved through the system, accelerating patient flow through the loop. This created a new
series of challenges for the HTT to adapt to and cope with. In the following section, I will

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detail what these difficulties were and how the team dealt with them, drawing out the theme
of process versus care.

The next three subsections use two interviews with the consultant psychiatrist Aubrey and
countless informal and formal discussions and interviews with team members to address three
issues. In order to understand how the practice had to be reshaped to fit the new political
economy of care, I must first explain why it felt like there was more work. How is it that
resource scarcity across the entire public support system and NHS has contributed to what
feels and looks like more work and increasingly acute patients? I will then look at how the key
to controlling patient flow is about what threshold there is for discharge and the difficulties in
figuring out where that threshold may rest and whether it should change. Finally, I will argue
that these decisions on practice have consequences, which are felt most by patients who
historically have received a poorer service.

Why Does it Feel Like Too Much Work?

In an interview with Aubrey, the Consultant Psychiatrist, we discussed managing the team in
a pressured environment. Despite the increase in patient flow and the pressure this put on the
team, Aubrey was committed to running the team in a way that would not compromise the
service they were able to provide. Much of his effort was put into managing the caseload and
trying to redirect the focus of team from granular aspects of care towards process and
throughput. He explained below:

(…) As long as everyone keeps concentrated on throughput, you know, that we

can create; that we won’t have such huge caseloads. I think that what tends to
happen is that when we are very, very busy, suddenly everyone becomes a bit
hysterical about trying to move people on; and then when it gets – when we’ve
managed to do it, everyone sort of loses focus.

Here Aubrey was trying to regulate the flow of patients through the HTT to keep pace with
other parts of the system but also to regulate the emotional stress on the team. The team
reacted to the stress of increased patient load in a way that was not necessarily conducive to

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maintaining the type of patient flow that Aubrey would have liked. The cumulative effect of
the stress of high caseloads and the turmoil it could bring could push the team into a reactive,
triage type mode. Aubrey described this below:

I think that’s right, if you’ve got no time and you are worked off your feet all
the time you can’t be flexible; it’s just the whole – the whole operation of the
team becomes consumed with going through long lists of people and every
handover, trying to do visits more quickly and trying to move people on and
trying to – struggling to take people into the team.

What Aubrey said above was no revelation about the increase in the number and flow of
patients through the team. The difficult part was when one factored in the complex
presentations of many of these patients because of the system-wide cuts to services, benefits,
and social care. Patients moved through the system so quickly that it made it difficult to
address specific and longstanding issues such as housing, social care, and chronic physical
health issues, all of which took time, inter-agency/team planning, and communication. For
instance, a longstanding issue could be a lack of adequate repairs by the housing authority
which had led to chronic problems with damp and mould. These problems and disrepair could
drive feelings of depression or despair that remained so long as the issue was unresolved.
Aubrey, the HTT’s consultant psychiatrist, had spoken about a need for a team that helped to
address the underlying complex issues driving relapses. In an interview, he dismissed the need
for a team, stating:

It’s more that the level of input that people can get when they leave us is sort of
high quality and is well resourced, and you know, addresses the problems we’ve
identified and often that just doesn’t happen. And there’s many reasons, and
you know, there’s resourcing reasons, and there’s social care reasons, and you
know, there’s a whole host of reasons why it happens. You know, it’s frustrating
and it’s very – it’s very sad for the person and it’s frustrating for us.

In the above quote, Aubrey called for high quality input that CMHTs and other services
could not provide as cuts to their funding had limited their ability to be effective, which in turn
affected the HTT. Part of the job of home treatment is to flag the long-term needs of patients
and to start working on these in hopes that other services will take over. As the CSL
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explained “our sort of raison d’être is stabilising that sort of crisis but also making clear
recommendations for what needs to go on in the future”. After the HTT withdraws, if
something goes wrong with a package of care and a patient misses a few appointments, there is
no flex in the system to allow CMHT staff to go out and find the patient. There was a time
when the CMHT visited their patients at home on a regular basis; now it is far more likely
that these patients travel to the CMHT to see their worker, a trip that can be difficult for
some patients.

With the increased speed and pressure in the services and the foundering ability of the
CMHT to follow up on the longstanding issues, the HTT can sometimes find itself stepping
into the role of a CMHT for a time and providing services that are out of its remit. A patient
who returns again and again with the same issues prompts a need to step in and provide what
other teams fail to do, which ultimately leads to a team argument about who is responsible for
this. Fortunately for the patient, home treatment is flexible enough to take on some of these
added responsibilities for a short time. As the CSL said,

(…) You’ve gotta think sometimes with home treatment, “well.. Fuck it”. You
just have to do it if no one else can do it. Whereas other people say, “well that’s
not the model, it’s not how we work. It should be the care coordinator’s
responsibility”. And it’s true that you’ve still got a patient possibly sitting there
with no gas, electric, or who’s running up rent arrears by the week or isn’t
getting dressed. Sometimes I think you’ve just got to do what’s right and what’s
quickest sometimes, but then also you don’t want to, if you’re going to start a
piece of work, you wanna make sure that it’s finished as well.

The CSL made an interesting point above, which is that “sometimes … you’ve just got to do
what’s right”. This is a normative plea for the quality of the service to be maintained for those
who are in the most need of it, who are often the most frequent patients—with the added
patient flow, patients who call for a more intensive service increase, as do the complexity of
the issues that are behind their cyclical relapses. This is only compounded by the fact that
other parts of the local social support system are not set up in a manner that allows for speedy

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assessment and intervention.32 Again, the team is faced with a question of how one serves the
needs of the Trust and the those of the patient at the same time if other aspects of the system
have repeatedly failed that patient. The question becomes, does this acceleration within the
mental health system mean that thresholds for moving patients on to the next service are
lowered? How do you choose who gets what level of treatment in the HTT?

Have Thresholds Changed? Will they Change?

I asked Aubrey about thresholds and he insisted that the concentration on process and
accelerated rate of discharge did not greatly change the threshold for discharge. However, the
threshold was difficult to define to begin with. There were no rating scales that indicated
when the threshold for discharge from a HTT had been reached. Aubrey defined it instead as
a series of conditions that needed to be met before discharge. For instance, the patient had a
care plan; the next steps of that plan were well organised, extending beyond the HTT to the
next service the patient would see; the patient had been connected with that service; and had
met a member of that team before their discharge from home treatment. These conditions,
once met, could provide some containment, aiding in the management of their condition.
Aubrey stressed that some of these things, that might have been left until the end of treatment
to organise, were now being moved to the beginning of treatment, to be “chased” to speed up
discharge. He denied that actual thresholds changed in any significant way.

We don’t change, I certainly hope we don’t – I don’t think we do – sort of

change practice in that someone you’d never think of discharging before you’d
just suddenly discharge, you know, and hope for the best.

There was a difficulty that arose here for the team and Aubrey, one that he addressed. There
was a dichotomy between “process work” and “caring work”. Aubrey called attention to this

32
The Trust used a panel to decide who received support and how much support they would receive. A panel of
people scrutinised the rationale/argument put forward by the care coordinator for support to be allocated to their
patient. The panel would then go with the cheapest option, often receiving much less time with a PA than the
care-coordinator argued for. The patient and care coordinator must then wait for this arrangement to fail (for the
patient to become unwell again); once it had failed, the care coordinator could return to the panel again for the
next cheapest option until it stopped failing.

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and the need for a concentration on process for the throughput model to succeed. He needed
the team to buy into this and not to think that “my job’s not to rush people through the team
it’s to like look after people”. The guidelines of how long a patient should be with home
treatment were meaningless to Aubrey: “if someone needs two months just for good reasons
than they need two months”. The payoff for the team in buying into this “process first” model
of throughput was the creation of time for a flexible, caring type work with specific patients.

So I think that will be the idea, everyone comes to recognize that if you do
that, what it allows you to do is have more time when you’ve got reasonable
sized caseloads, when you can keep people on for longer than you otherwise
would have, where you can do pieces of work with people where otherwise you
might not have had the time to do, all those sort of things and I think that is
achievable.

The difficulty the team had with this “process first” model was in deciding who got that time.
Who should have the extra input? In a time-starved atmosphere, the team relied on their past
experiences of patients to help guide decisions in the present. This reliance on past
experiences allowed the team to make the most of such experiences but also contributed to
ideas about who might be a “good” or “bad” patient. The team’s standard for being a “good”
patient was based on the ability to understand the patient; develop a rapport quickly; frame
their issues in a way that could be intervened upon; and for the patient to engage in the way
the team thought they were capable of. These were the patients who were likely to get an
extended service from the team. They may not have necessarily been the ones who needed it
the most or could benefit from it the most. There was of course a wide latitude given to
patients who fell outside of the above parameters due to extreme illness but only for a limited
time until the team lost their ability to empathetically connect with that patient. In a resource
and time-starved environment, team members were less likely to keep a patient that fell
outside the parameters of a “good patient” with the team; instead they would look to
discharge the patient.

The potential for thresholds, empathy, and patience to wear thin with a particular group of
patients is a real problem that exists outside of this particular setting, but should raise some

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concerns when the team shifts into this “process first” model. Individuals who are labelled with
a personality disorder like borderline personality disorder (BPD) often face stigma from within
the mental health system and studies have shown that this can reduce the services and
resources available to them (Bodner et al., 2015; Bonnington & Rose, 2014; Sheehan et al.,
2016). Many of the team’s “bad” or difficult patients had a label of personality disorder or a
mention of “personality traits” in their notes. This was not necessarily a clinical diagnosis;
instead “personality” has been used as a short hand in electronic notes for “difficult” patients in
the NHS. The way that a clinically diagnosed personality disorder was dealt with by the team
and mental health services in general created an expectation by team members of a certain
pattern of behaviour. A team member explained to me that personality disorder referred to a
set of behaviours like “using self-harm to manage their emotions” or “someone who will ask for
help and yet refuse help at the same time, which can be really frustrating for people in the
team”. They continued:

It’s a term people use and sometimes a person might have that diagnosis and
sometimes they might not, but they’re – they might be portraying those
behaviours and it’s a commonly recognised; like when someone says that, you
know what they mean, sort of thing. So it’s – but because people use it
inappropriately, it just gets used too much. It’s not really fair who might, you
know. They’re new to the services, we’ve never met them before, someone’s
met them once and then says, oh I think they’re… And they might be right,
and people are experienced in working with personality disorder and you can
pick up on those traits very quickly. I think, overall, it’s really quite damaging
because overall it reduces people’s sympathy and understanding, and I think it’s
quite common, in every team I’ve worked in it’s been a common theme.

As the team member stated above, the label of personality disorder or the mere mention of it
in notes could drastically change the way that a patient was handled by the team and
subsequent services, something which has been backed up by a number of studies (Bodner et
al., 2015; Bonnington & Rose, 2014; Latalova et al., 2015; Sansone & Sansone, 2013). As an
example, one HTT patient repeatedly refused to go to accident and emergency when she was
unwell and in crisis because of the way she had been treated by staff there. Her notes claimed
that she had a personality disorder. Months later, she sent a letter to the team thanking them.
I mentioned that the letter came in to one of the staff and handed them the card. She said,
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“Now there’s a woman with personality disorder”. I asked her if she really thought that this
patient had personality disorder. The staff member paused, and said ,“No, she had complex
trauma in her life but not personality disorder”. She followed this up with “but that’s what you
get in an NHS that can’t distinguish between psychological issues and problems, and full on
personality disorder so everything remotely psychological becomes personality disorder and
that’s that. You’re borderline”. She told me that this particular patient had ended up with
clinical notes claiming that she had personality disorder because she asked to see one worker
at a CMHT and not to see other workers. When it came to people who actually suffered from
personality disorder, team members often commented on how badly they handled patients
like this. Part of the reason for this was elaborated on by a psychologist who joined the team:

If you don’t understand how to help someone with personality disorder you’re
going to lose your compassion incredibly quickly and it happens. I’ve been told
that one of the things the team struggles with is working with people with
personality disorders to the point where it’s like “well actually this service
doesn’t work”. It’s not true, the service works with them if you use it in the
right way. Very, very brief admissions, sort of, for what are brief crises in people
with personality disorders due to the nature of their emotional disturbance, and
inability to regulate emotion, and the high levels of expressed emotion, and not
having anything to be equipped to deal with that. Our most traumatised people;
these are a group of people who have the most trauma, but yet we’re saying
actually we can’t tolerate them.

The admission at the end of this quote shows the serious nature of applying this label.
One team member pointed out that sometimes the best way to approach each visit was
“without memory or desire”. This was an explicit reference to a widely read and influential
paper by Wilfred Bion, who stated, “the psychoanalyst should aim at achieving a state of mind
so that at every session he feels he has not seen the patient before. If he feels he has, he is
treating the wrong patient” (1967). What I am trying to raise here is that there are times when
the approach to particular patients may be dismissive and default to discharge because patients
appear a certain way, say particular things, or have a particular history. Sometimes a patient’s
history or a team member’s experience is given more weight when making decisions in a time-
starved environment. Memory and desire enter into the evaluations of patients in a way that
can prejudice the choice of what patient moves on and what patient receives more time with
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the team. There is a need to slow things down and take a second look at patients, outside of
the framework of electronic notes and diagnoses, without memory or desire. Bion, as a starting
place, is necessary in a pressured environment. There will always be patients who challenge
team members’ empathy or compassion by breaching the traditional notions of the sick role in
any number of different ways, but they may also be patients who desperately need more time
with the team. Ultimately, the development of a “process first” model comes with an
expectation of difficult decisions that come with difficult consequences.

The Consequences of a “Process First’ Model?

As I argued above, there are difficult decisions to be made that sometimes require a second or
third look at a patient before moving them onto a lower level of care. The speed and pressure
levied on the HTT by management hungry for cost savings makes the difference between a
difficult patient and one who is deliberately not engaging difficult to see. The decision to
discharge prematurely has the potential to create a patient who revolves through the loop and
appears again in a more acute state weeks or months later. What are the potential
consequences of the “process first” model in dealing with pressure and maintaining patient
flow?

First it should be said that Aubrey was managing the HTT in a way that allowed the pressure
to move through the team with the hope of avoiding any significant disruption of the practice
of the team. Having said that, at a bare minimum it should have been possible to retain the
elements that made the team effective while concentrating on throughput. Ultimately,
Aubrey’s goal was to avoid the deterioration of the service into a type of triage service for
holding acute patients in the community. Aubrey made it clear that his focus was to make sure
that the threshold for discharging patients was one that was reasonable and that allowed for
the treatment of an ongoing crisis. That being said,

The dilemma is, you know, how do you operate under pressure and do things
which aren’t bad for people? And the answer is you can’t always do that; and
you often discharge people before you’d ideally like to and that’s just
unavoidable.

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The potential consequences of the “process first” model, and more generally the political
economy of care, can be expected to impact most those patients who are already subject to
substandard care, especially if they are a group of patients who are over represented among
adult mental health service users (Davie et al., 2014). A team member explained below:

I guess an evidence-based observation really: I think if you’re not white, I think

especially if you’re black and non-British and don’t have a good command of
the English language and so are less able to advocate for yourself; I think you
are less likely to get a good service from this team. I think you have a
continuum and at one end you would have a demographic group who are white
and middle-class regardless of their gender and at the other end you would have
the black and non-British client group, and I think that your success in getting a
good service from this team will largely be determined by where you are on that
continuum.

It is already known that Black and Minority Ethnic (BME) patients receive a less than fair
mental health service (Davie et al., 2014), have a poorer experience with mental health
professionals than white patients, and are less likely to put trust in a system that often mimics
incarceration (Memon et al., 2016; Sewell, 2012; Tegnerowicz, 2018). As they are less likely
to trust the system, they are more difficult for the team to develop a rapport with and engage
with. I saw numerous instances where young black men and women found it difficult to open
up to mental health workers who they saw as not only having the ability to forcibly treat them
with powerful medication, but also the power to ignore their needs. Recently, and for the first
time ever, the Royal College of Psychiatrists released a statement on racism and mental
health, supporting the need for psychiatrists to “[reflect] on their own perspectives, behaviours
and the role unconscious bias can have on the care they provide” (2018:3). When I
interviewed Aubrey, I spoke to him about the things I had heard from the team and the
proposed racial continuum of care. He responded:

I mean, that’s possible. […] I did something with a social worker who was
previously in the team where we looked at length of stay and its relationship to
ethnicity, and we took people from the ward, looked at people who had come
off the ward and then came to the home treatment team. And first of all, are we

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 taking similar people to the people on the ward or are we only taking a sort of
subgroup of say, you know, more Caucasian or more woman or more, well,
etc.? So, it seemed that [the] people we were taking off – this was five years ago
– but the people who were taken off the ward were pretty much the same as
the people on the ward, and that the length of stay of the black and white
patients were the same in home treatment. So [it] wasn’t shorter or longer, but
on the wards it was longer for black patients and shorter compared to white
patients. So, I mean, it would be interesting to do that again, but I think that
generally, yeah. I don’t – I’m not aware of that, but I think it’s always worth
trying to be aware of it. I think there will be – if there’s a background of
violence, I think that will probably, people will probably want to move people
on but I don’t – but I think, I don’t know if it’s a – I don’t think it’s – but it
would be interesting to know. But if you – but if there is a history of violence
and it doesn’t interact with ethnicity, it would be interesting; but I don’t even
know if there is a history of violence that predicts shorter stay. But it may.

The team led by Aubrey had done the work in the past which compared length of stay and its
relationship to ethnicity. The consultant was tuned in to the difficulties, as was the team, of a
population that was over represented and received a poor level of care. There are still issues,
as team members pointed out to me. What is interesting about this has to do with the lack of a
reaction from the Trust. It is perhaps unsurprising that the Trust was unable or unwilling to
engage with the Black and Minority Ethnic (BME) community at the most basic level of
service provision, despite the fact that there was a direct connection between service provision
for the BME community and cost savings.

Research from the Sainsbury Centre for Mental Health Studies on SLaM have shown a
significant difference between the cost of care for BME patients as opposed to white patients
(2006). Black patients tend to have longer stays in inpatient wards, more acute presentations
requiring time on PICU units, and less interaction with primary care for mental health issues
(Ibid). All of this accounts for a higher per capita spend on services than for white patients,
meaning that if the Trust could invest in services and support that would bring expenditure on
black patients in line with white patients, between 9.1% and 10.2% of total expenditure on
mental health service for adults could be saved (Ibid). An intervention that would bring about
equity here would bring down the high level of acuity among black patients and significantly
reduce the use of PICU units, which are much more expensive to operate than regular units.

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Certainly, the inequity that BME patients face is not new as it has been studied for more than
30 years (Grey et al., 2013) and yet the Trust failed to even mention the BME community in
the consultation documents. Although the Trust put such an emphasis on data for finding
efficiencies, they blatantly ignored the data already collected on the potential for better care
to be offered to black patients and cost savings to come because of this. The political economy
of care is not about quality or equity; rather it is about saving money in a way that requires no
extra effort. The team on the other hand was locked in a struggle to maintain a service
stretched to the limit and forced to concentrate on process work over caring work.

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Chapter 8: Time, Space, and Resource Scarcity in Service User
Experiences

This chapter will explore how austerity and resource scarcity influences service user
experience of the HTT and mental health services in general. The Trust’s political economy
of care reshape service user experience by accelerating service user movement through mental
health services to expand capacity. To conceptualise this acceleration and explore its effect on
service experience, I use Barbara Adam’s concept of timescapes (Adam, 1998a; 2008). I begin
by introducing timescapes in mental health services and the clash between personal and
institutional timescapes. Institutional timescapes are then examined to explore their effect on
experience and service user transitions between services. Following this, I conceptualise and
explore time-space compression and its effects on service user experience, detailing how
compression exists both in service user narratives and in the digital versions of those
narratives. I then examine the side effects of speed, one of which is abbreviated thinking and
its disproportionate effect on black British service users. Finally, I look at the other side effect
of speed, a devaluation of the self.

Timescapes and Temporality in Mental Health Services and Service Users

Service users move through the mental health system; they enter in it a variety of ways and
tend to pass through multiple services designed to treat the disorder(s) from which they are or
might be suffering. The key point here is that they move through this system and this
movement occurs across a particular period of time. To understand the experience of home
treatment as being in isolation from the other parts of the mental health system fails to
recognise that service users rarely begin with the HTT. Instead, they carry experiences of
other services with them. To understand their experience of the HTT, it is crucial to begin by
investigating their experiences across the mental health system and through time. To explore
how movement and time affect individual service user experience, I will utilise the concept of
a timescape developed by Barbara Adam by adapting it to the context of mental health in the
UK (Adam, 1998a; 2008).

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According to Adam, timescape is a concept that seeks to add a temporal perspective in
research. A timescape is a “cluster of temporal features, each implicated in all the others but
not necessarily of equal importance in each instance” (Adam, 2004:143). The “scape” is meant
to symbolise the fact that “we cannot embrace time without simultaneously encompassing
space and matter” (Adam, 2008:3). The temporal features have been referred to differently
across her work but Adam’s more recent work includes seven: time frame, temporality,
timing, tempo, duration, sequence, and temporal modalities (Adam, 2008). Timescapes are
embodied, social, and structured but also interdependent, occurring across and/or overlapping
many different timescapes (Adam, 1998a). So, what timescapes/temporal features are
involved in mental health care?

Timescapes within mental health care telescope outwards from the smallest, simplest elements
of the body that play an intricate role in treatment, to social and institutional timescapes. For
instance, an embodied timescape encompasses metabolic activities that control the time it
takes lithium to transition from oral ingestion to blood supply; the time it takes to acclimatise
to an antidepressant; or even the duration of a psychotic episode. This embodied timescape
extends into the environment with the sleep-wake cycle and circadian rhythm. The rhythms
of daily life feed into personal embodied timescapes: the routine of taking pills; making
breakfast, lunch, and dinner; the schedule for a week, a year, or a five-year plan. Clock time, a
sort of social timescape, controls much of our lives, dictates our movements from place to
place, the time of home visits, or the length of stay with a service. Mental health services often
have their own timescapes and rhythms that work to compete, challenge, and subordinate
personal timescapes.

One of the main focuses in my analysis of timescapes is the interaction between institutional
and personal timescapes. Acute wards, HTTs, and CMHTs all have their own timescapes
that involve different temporal frameworks: for example, the timing of the service (when it is
received, when one is eligible); the tempo of the service (what speed does the service move at,
how long the visits are, assessments, the routines of a ward, daily home visits); the duration of

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the service, the sequence of the service (twice a day, once a day, once every other day) or
sequence within services (ward to HTT to CMHT)—all differ across mental health services.
In addition to this, the point at which a person is perceived to have recovered sufficiently to
be discharged differs between teams. The example below highlights the overlapping and
conflictual nature of institutional and personal timescapes. It focuses on Caitlin’s experience
being admitted to the HTT via the A&E and Psychiatric Liaison Service (PLS).

Entering the HTT through a hospital A&E department illustrates a movement through
several different and conflicting timescapes. When Caitlin walked into the A&E, she was
immediately seen by a triage nurse. This interaction formed the intersection between two
timescapes: Caitlin’s personal timescape and that of the institution. The nurse’s job was to
translate Caitlin’s symptoms into a timescale that fits the tempo of the A&E, the government
targets for waiting times, the available staffing level, and the expectations of the service user.
In this process, Caitlin’s timescape became subordinate to that of the A&E. Caitlin began by
describing the process of being evaluated by the PLS. She was led to a small cubicle and
assessed by a psychiatrist. She gave in-depth answers to their questions and was later assessed
a second time on the risk she might pose to herself or others. She commented on this
experience in an interview with me:

It’s like your future is determined in that period of time, you know, as to where
you are going to end up and how this is going to turn out because you are not
sure of yourself. You don’t know, I mean I honestly thought I would be
hospitalised because the psychiatrist said I was high risk, but the counselors
said, “you know, we don’t like to hospitalise people unless it’s the last resort,
absolutely necessary”. So then the home treatment team became involved and
that was, you know, they thought that would be better for me.

The experience in the A&E is shaped by a rhythm of long periods of waiting in between short
but intense exchanges of information (assessments). Caitlin broke up her time waiting in the
A&E by watching Netflix on her phone to keep from becoming overwhelmed with emotion.
In doing so, she brought herself temporarily out of the institutional timescape by focusing on
something that provided a distraction to her. This is a good illustration of overlapping

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timescapes as the personal and institutional timescapes shift from foreground to background
with neither being eliminated entirely.

While most of what happens in the A&E happens in the present, the institutional timescape
also extended into Caitlin’s future. Decisions made in this encounter would affect Caitlin for
weeks, months, and even years to come based on the course of treatment decided on and the
path or trajectory of her service use. Ben Hannigan and Nicola Evans point to these moments
as “critical junctures” which they define as “a temporally bounded sequence of events and
interactions which alters, significantly and in a lasting way, both the experience of the person
most directly affected and the caring work which is done” (2013:428). Caitlin was aware of the
importance of the decisions being made and yet had very little input on directing that
trajectory apart from adjusting her own timescape within the interaction.

The PLS eventually decided to admit Caitlin to home treatment on behalf of the team. When
they communicated this to her, they described HTT as “like the hospital but not in a hospital
environment”. This description of home treatment allowed Caitlin to develop some
expectations around what the HTT would be like and how it might or might not interfere
with her timescape. The way Caitlin and many others experience home treatment is shaped as
much by the HTT’s actions as it is by the actions of other services that she encountered.
When Caitlin interacted with a part of the mental health service, she was also interacting with
the sum total of her previous memories and experiences of other mental health teams. In this
case, admission to home treatment came as a relief to Caitlin because of past positive
experiences with home treatment; for others these experiences are not always positive.
Experiences and memories are often refracted through the difficult nature of crises, sometimes
heavy medication, and/or a disorienting titration onto medication. This can distort them and
turn what may have been a neutral experience into a negative one; but it can also create a
lasting trauma from a negative experience(s) that colours the way that service users interact
with services going forward. To begin to examine this, it is necessary to first look at the
differences between institutional timescapes and then where the friction is between these
timescapes.

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Institutional Timescapes and Service Rhythms
For service users, it is difficult to adjust to the timescape of the acute ward. This is because
they must acclimatise to the temporal rhythm of the ward while undergoing the effects of a
rapid titration onto powerful medication. This is often a disorienting experience and the
potential for chaos on acute wards can make it even more difficult. Acute wards have by and
far the most restrictive timescape, with locked doors, routines, scheduled meals and activities,
and a strict no smoking policy. They are purpose built to minimise risk, which means spatially
they are built so that there are no ligature points or areas where a ligature can be attached
(Curtis et al., 2013). Movements outside of the ward for those under section are timed events
and mostly under supervision. Visits from family members are only allowed during certain
hours. Service users experience their own timescape as being subordinate to that of the wards.
Some find this incredibly comforting and predictable, making it difficult to return home to a
less strictly orchestrated routine, while others find it challenging to adapt to the regimen of the
ward.

In comparison to the acute ward, the HTT has a timescape that is essentially only present
when a team member visits a person’s home. However, it does exert an organisational force on
the individuals’ life, in that they know they ought to at least get out of bed and get dressed to
answer the door twice a day. It provides a rhythm to the day that is different from the ward
but helps to acclimatise the individual to the regular pace of life. The environment is one that,
while maybe not be as comfortable as the ward (or comfortable at all), is familiar and mostly
under the control of the person being treated. The HTT also works to ensure that service
users are continuing to take their medication and develop the habits and routines to make their
medication and recovery successful. Transitioning from an inpatient ward to the home is
difficult but, as one service user put it:

Home treatment is very good for giving you a grounding when you are first
back, when everything seems a bit odd and a bit bewildering, and you’re quite
fearful even in your own home … I recognised some [team members] from the
first time, so all of that is quite reassuring … initially when you are unable to go

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 out … of the flat, just come back from the ward, and you’re finding it very
difficult because of what you are trying to understand about your condition,
that you can’t leave the flat. And then home treatment come around and
deliver your medication and they observe you taking it which needs to be done,
but also they can bring items if you need them. So I remember getting a loaf of
bread or some milk ... I could have gotten it myself, but I just couldn’t build up
the confidence to do it because I was recovering from this mental shock – that’s
how I view it – as being a huge mental shock which takes xxx to recover from.

Part of recovery for service users is (re)developing the regular routines of life (or timescape).
This service user found it difficult to immediately (re)assert his routine. He explained that he
was quite fearful when first arriving back home and it was hard to make sense of the
repercussions that came with his diagnosis. He spoke in this interview about how he needed to
come to terms with the diagnosis, how it would shape his future, how it reshaped his past, and
the subsequent steps he would have to take to avoid this again. Home treatment was able to
step in and provide the right kind of support to help him (re)establish a routine and sense of
security in his own home and in doing so, team members supported his recovery. The rhythm
to home treatment, as I have mentioned, is one of home visits but there is also a rhythm in
relief of this. There are long periods of waiting in between visits that can be frustrating and
difficult to plan around as team members often come and go as is convenient.

CMHTs have timescapes that are often disrupted by chronic underfunding and a lack of staff,
and differ in comparison to the services above. Following discharge from home treatment to a
CMHT, many people have a recommendation for therapy but then face long waiting periods
creating a rhythm/timescape of compressing/suppressing difficult emotions and experiences
while waiting for their next decompression with a therapist/service. The experience of
CMHTs by service users is often vastly different depending on the care coordinator and the
service user’s expectation of what is possible. Meetings with CMHTs are often sparse, with an
average of two a month, which means if a meeting is missed, an entire month will go by
without face-to-face contact with the team. The rhythm that is constructed by CMHTs is one
of intense periods of engagement followed by long waits. The difficulty with long waits is that
often, once a service user reaches the top of that waiting list, they are so destabilised that the
service is uncomfortable handling their care. Some psychological services will refuse to treat
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individuals if they are too unstable, producing a situation where service users who have waited
are bumped back down the list and out to a more intensive level of care. For example,
Elizabeth told us:

I had DBT. Oh, there were all these Dramas because I had some therapy at the
------- the year before, psychodynamic which isn’t good for me, and then when
these guys [home treatment] discharged me in January, they said “we
recommend a CAT referral”; and then the CMHT were like “no she’s had it,
she’s had therapy she’s got to wait three months”. So they didn’t do the
[referral]. These guys thought they would do it straight away but they didn’t
because they were like, you’ve got to have this break. In that meantime, I split
up with my boyfriend and took another overdose and I just got worse because I
had gone from a traumatic experience in the hospital, then really good support
here, expecting at least a referral and knowing I would have to wait, but then it
wasn’t done. So, I got worse in the meantime because of things outside of my
life, and just other work stuff was going wrong and my life was still bad, it was
still bad. They did the referral eventually, but then, because I just got worse I
took – I took another overdose in… I took a really bad one in April last year, I
think I nearly died, I think I nearly died.

While waiting, Elizabeth was destabilised by stressors in her life. She had constructed her
personal timescape around a referral to a service and an expected date to start therapy. This
personal timescape was created with a rhythm of waiting that was familiar to her from past
experiences of services. With the expected start date for therapy known, she could have
constructed a trajectory that involved an eventual point at which she would be able to
decompress the events that transpired within that waiting period. To Elizabeth, the HTT
listened and understood what her needs were, and her care coordinator and the CMHT
disrupted this trajectory and her personal timescape/rhythm. With no referral and no
expected start date, Elizabeth had no imagined future where help was waiting, making it
difficult to deal with emerging distress.

The differences between each of the mental health services and their timescapes make not just
for difficult waits, but also difficult transitions between the teams. For example, the HTT will
often try and step down their involvement with a person so that by the time they are
discharged to the CMHT, they are down to one visit every other day or even less. This is

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done so the corresponding drop in input does not come as a shock. Transitions between teams
and between timescapes are often points where service users are taken completely out of their
own timescape—some transitions can be jarring or much worse.

Difficult Transitions Between Personal and Institutional Timescapes

Transitions between services are often difficult and destabilising for individuals as they involve
a process of adaptation to different timescapes or the (re)establishment of a timescape. These
crucial moments have a powerful effect on service user experience in general and also
contribute to the experience of the HTT (Hannigan & Evans, 2013). The most jarring
transition a person can have is being “sectioned” or being put under mental health section to
be forcibly treated in an inpatient unit. This involves a transition that subordinates the
individual’s personal timescape and superimposes an institutional one. This is increasingly
becoming the standard way of entering inpatient wards, as there are rarely enough beds for
those who wish to voluntarily admit themselves.

The use of compulsory detentions, as reported by the Care Quality Commission (CQC), has
gone up in recent years (2005-06 to 2015-16) by 40% (2018). The rise in compulsory detention
has been studied by several different researchers showing an association between the closure
of 60% of acute beds between 1988 and 2008, and a corresponding rise in compulsory
detentions of 64% (Keown et al., 2011). The CQC are confident that this is a result of a
mental health system under strain, but they also speculate that it “might amount to a vicious
cycle where pressure on beds leads to clinical practices that increase the likelihood of patients
being detained, which itself increases the pressure on beds” (2018:4). The CQC fails to
suggest or identify which clinical practices might be driving this. I argue elsewhere that this is
related to the new political economy of care and the corresponding speed and pressure placed
on services.

Compulsory detentions refer to being detained and/or treated under a “Section” of the Mental
Health Act (1983), which in effect is to have one’s timescape dictated by mental health
professionals. The process of detaining an individual under the Act can be resource intensive

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and involve multiple services. As such it is managed in a way that minimises, as much as
possible, the costs of carrying out a detention. The emphasis on rationing resources produces a
quick and efficient process and an experience that can often disregard service users’ concerns
and cause a corresponding loss of trust in mental health professionals, police, and even family
members. If a service user does not heed the system and conform to the corresponding
spatial/legal timescape of the Mental Health Act section, it can and will carry them away
violently.

I interviewed several persons who related experiences of losing trust in mental health
professionals through the process of being sectioned and the timescape it imposed. Siobhan,
an older Irish woman who had a long struggle with bipolar disorder, experienced the loss of
two family members when her brother committed suicide and the father of her children died
in the span of only a few months. At the time, she was with a CMHT and was sectioned on
Christmas Eve, spending six months away from her children. The consultant who sectioned
her on Christmas Eve said to her during the process, “I don’t expect you to trust me”. About
which, Siobhan asked me, “How can you have a therapeutic relationship with that?” She
recalled a time she was suffering from a severe chest infection and water on her lungs. She
went to the A&E and no one approached her for 19 hours until after a consultant psychiatrist
and social worker sectioned her. This left her feeling as though she had no rights as a
psychiatric service user. Siobhan’s attitude now was to do whatever it took to stay out of
hospital, which often involved ignoring warning signs and not seeking help when she needed
it. Others seek help but rarely find it in time.

Miles, a young black man, spoke to me about feeling like no one listened to him when he was
ill. He had a history of admissions to the HTT and acute wards and had lost trust in the
system. His most recent admission began with him seeking help. He called his care
coordinator to tell them that he was becoming unwell after the mother of his baby threatened
to commit suicide. He then went to the police station to say that he was not feeling well, and
he sat there all night without the police calling an ambulance. He finally managed to see
someone in an A&E department where he was given more medication and released, despite

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not feeling well enough to be in the community. Miles was searching for help, but was turned
away everywhere he went. As his mental state deteriorated, confused and frustrated, he
scoured central London for a department store. He was finally approached by police in a fine
dining establishment and tasered. Miles was then brought to a 136 suite where he was
sectioned.

Miles and Siobhan were both sectioned and then moved to wards for treatment under the
Mental Health Act. The intervention transitioned them, from their personal timescape and
the rhythm of their daily life to an institutional timescape that asserted near absolute control
over the rhythm of daily life and sought to foster new rhythms or stabilise old ones (taking
pills). The juncture between a personal timescape and spatial/legal timescape of a section can
be jarring, and although uncommon, in this final example of transitioning to the ward, it can
also be violent.

A Mental Health Act assessment that leads to a section is a feat of orchestration. It requires a
police presence, an ambulance, an independent psychiatrist, and an AMHP, all of whom are
on the clock and only available for a limited period. The purpose of this orchestration is to
ensure that there is a smooth transition and that the spatial/legal requirements of the section
are carried out humanely. The difficulty is that with constraints on time and resources, speed
is essential and with speed comes accidents. Virilio (1997) called this difficulty with speed the
dromological law—an increase in speed brings with it a higher likelihood for gridlock. Simply
put in this case, with all of the resources (police, AHMP, ambulance, psychiatrist) being
orchestrated at a high rate of speed, we can imagine it as though it were a gear-based system
that moves steadily. If one gear seizes while the system is moving at speed, the results would
be an immediate and violent gridlock. The following is an example of such a seizure during an
MHA.

Valerie, a West African woman in her 60s, was suffering from psychosis. She lived on the top
floor of a council block and had been a home treatment service user for a few months. The
team had trouble deciding whether she was making progress and worked with her consistently

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over this time as steadily her behaviour became increasingly risky. The team decided to
section her as they believed she needed treatment in an acute ward that would be monitored
and in a neutral place. The AMHP gathered and orchestrated an independent psychiatrist,
four police officers33 and an ambulance (which arrived a bit later). We met at the bottom of
the tower block, taking the elevator and stairs to Valerie’s flat.

Once inside, the AMHP calmly explained what was happening and why Valerie had to go to
the hospital with us, forcibly if needed. Valerie paced between rooms and argued with the
psychiatrist. After a total of about 15 minutes had elapsed, the police, who were standing
outside the flat, came in, letting the AMHP know that the ambulance had arrived. The
psychiatrist explained once more to Valerie why she was being detained, and made it clear to
her that she was now under a section of the Mental Health Act and must comply. Despite
this, Valerie refused to leave and the four police officers moved in. They began to forcibly
remove Valerie, who was dressed only in a robe, from the flat. It took ten minutes for all four
police officers to restrain her, forcibly move her from the top floor, all the way down to the
ground floor via the stairs, while Valerie screamed and yelled. Residents popped out of their
flats, filming with cell phones and cursing at the police for being rough, as the AMHP
desperately tried to cover Valerie with a blanket. The orchestral arrangement of the services
failed when the subject was unwilling to cooperate. The institutional timescape backed by the
spatial legal powers of the MHA took hold of Valerie and in the process recreated a scene that
was all too familiar in her community—a black person being forcibly and violently removed
from her flat by four white metropolitan police officers.

As we emerged out onto the ground floor, residents from other buildings spilled out of their
homes to watch as Valerie was frogmarched by the police to the ambulance. It took 40
minutes from start to finish before everyone was in a vehicle headed towards the hospital. The
police were already radioing in for their next assignment. The march of institutional and legal

33
I criticised the use of four police officers for the section and the AMHP told me that this decision was out of
her hands and that a riot squad had recently shown up to section an elderly blind man, presumably because he
was black.

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timescapes continued unabated. A person can lose trust in the system and the system can stop
listening to them, but if they do not heed the system and conform to its timescape, it can carry
them away violently. Valerie’s experience is very much the exception and not the rule, but it
illustrates an orchestration of time and the power that lies behind a section and that follows
service users into acute wards. It also illustrates the restrictions put on time and the danger of
acceleration when orchestration of multiple resources fails to meet the needs of the situation.

Time-Space compression in Timescapes

The speed at which Valerie was transitioned to the ward and the violence of doing so are
unfortunate reminders of the difficulty of running a mental health system under pressure and
with speed. The pace of treatment has accelerated over time as the mental health system has
evolved from asylums and day programmes to HTTs and triage wards. It was once possible to
have an abundance of time to spend with service users and observe them; now the emphasis is
on rapidly assessing, stabilising, and discharging service users with an eye towards the
management of costs. I do not have the space to track the development of time-space
compression throughout the rise of care in the community. Instead, I will focus on identifying
three different streams of time-space compression present in my research below. The first is
the actual service user experience of time-space compression in the mental health system. The
second is a time-space compression of the narrative service users tell. The third is a further
compression of these service user narratives through a technological nexus. To explore these
in more detail I will begin by explaining and defining time-space compression.

What is time-space compression? I borrow the concept from David Harvey (1989) who argues
that Capitalism has been in the process of compressing time and space since the industrial
revolution. For instance, with the advent of the airplane, travel between London and Paris
was cut to a few hours, compressing the space by time. Harvey’s logic entails that:

In times of economic crisis and of particularly intense competition, capitalists

with a faster turnover time survive better than their rivals, with the result that
social time horizons typically shorten, intensity of working and living tends to
pick up and the pace of change accelerates. (1990:425)

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I use this concept of time-space compression on the much smaller scale of the mental health
system. Home treatment is itself a time-space compression; it creates a virtual ward where the
catchment area of the team is the space of its ward and the homes of service users are the
rooms they reside in within that ward. The Trust, mired in its own financial crisis, has used
the HTT and its virtual ward to (re)organise its approach to resource scarcity, utilising it to
manufacture cost efficiency during peak periods of demand for services by diverting excess
service users to the HTT. The Trust, like stock markets before it, is “learning to play the
volatility right (…)” to be able to react to an increase in service use without driving up the
costs (Harvey, 1989:286). This involves “short-term rather than long-term planning, and
cultivating the art of taking short-term gains wherever they are to be had” (Harvey, 1989:287).
These short-term gains could be anything from using less staff and faster discharges to
elements of ward design that allow for the use of less staff without increasing risk significantly
(Curtis et al., 2013; Gesler & Curtis, 2007). One could argue that what I am claiming here is
that service users circulate through the mental health system like capital circulates, adjusting
the movement and speed at which patients’ flow allows the Trust to manage their
expenditures and their capacity. As Harvey asserts, this has consequences: “time-space
compression always exacts its toll on our capacity to grapple with the realities unfolding all
around us” (Harvey, 1989:306). Time-space compression within the mental health system
emerges through compressed narratives and experiences of service compression.

What is the Experience of Time-Space Compression Like?

Throughout the interviews and discussions I had with service users, the experience of
compression and decompression in treatment across mental health services came to the
surface. The time-frame of the ward is measured in hours, days, and weeks, producing
treatment strategies that concentrate on short-term interventions that rapidly assess, stabilise,
and discharge service users. This pressure and focus on the immediate, combined with

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overworked and chronically understaffed wards34 produce a particular service user experience.
For example, Olanzapine is a fast-acting antipsychotic that is commonly used on wards for
rapidly stabilising service users experiencing psychosis. The difficulty with using Olanzapine is
the long-term side effects dramatically increase cravings for sweets and can cause serious
weight gain. When treating Diane, a woman with a history of an eating disorder, the balance
was between the benefit of short-term stabilisation and discharge versus long-term difficulties
in controlling cravings and the eventual disruption of eating disorder coping strategies. The
pressure in the ward created a situation where short-term solutions were chosen, leaving other
services to (hopefully) deal with the long-term consequences of those decisions. When I spoke
to Diane about her experience on the inpatient ward, she remarked on how it was like the
movie One Flew Over the Cuckoo’s Nest. This experience frightened her, making her feel
like she was lost.

Yeah, it’s quite sad because, the truth is, a lot of people need their [Staff] help,
like I said when I was at Triage a lot these of patients needed their help and the
support, never got it, no one listened, and they didn’t listen to me either. I
mean every time I say something no one wants to listen to me and it just kind of
made me feel like I got lost there, and I’m thinking I got to get out of there, I
got to get out of there because those poor people they are drugged up to their,
you know, the hilt or whatever, and you know they’re just not there.

Diane reflected on being lost among people who desperately needed help but were not being
heard by staff on the ward. Her own long-term needs were lost among the pressures of the
ward and the short-term solutions that it brought about. The solution compressed her needs to
the immediate days and weeks after release from the ward, disregarding the longer-term
difficulties that would no doubt be caused by this approach. This had a profound impact on
her, even leading her to question whether the staff hated her in an interview I conducted with
her. Other service users related a different feeling, one of slowly decompressing: an embodied
experience of the heavy drugs (haloperidol) that slow service users down in uncomfortable

34
On more than one occasion I overheard staff in the ward complain about not being able to ensure the safety of
everyone on ward because they were understaffed. In conversations with student nurses I was told about a ward
where a student nurse was left the nurse in charge with only two other nurses on staff for at least 10-15 patients.

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ways, drugs that they were immediately started on when they arrived. Here compression is
experienced as a fog that slowly lifts (decompresses), allowing them to gain an awareness of
the situation they are in.

It’s like fragmented memories, if you understand what I am saying. It’s like you
– things happen, and you remember small little things but then, it was like kind
of surreal – you don’t remember the whole process, you just remember one
second in your head, one second in your head, one second in your head, and
somethings it doesn’t make no sense whatsoever, sometimes you don’t even
know where you are.

This frame by frame memory slowly decompresses, increasing their memory retention,
eventually gaining narrative significance. In this case, these individuals experience an
embodied compression, expanding slowly back into a full sense of what is happening as they
acclimatise to their surroundings, the timescape of institution, and the powerful medication.
The expectation that they might recover on the ward is also quickly erased as they are only
stabilised on the ward and then discharged. This creates a disjuncture between the slow
recovery and quick movement between services, as the progression that a service user follows
from one service to another is not directly linked to their stage of recovery. Services often
discharge before service users feel they are completely recovered and/or ready to go home.
For example, one service user reflected on his return home and the process of recovery,
explaining that it

can seem pretty bewildering because you’ve got to do your normal everyday
tasks again, which for a period of just the recovery – just the admission to
discharge might be a month, and then the ultimate recovery through all the
processes might take another two months. But the problems that led to the
admission, they might be any amount of time.

The disconnect between recovery from his relapse and his movement through the services is
evident in the above quote. The individual’s time frame for recovery is independent of the
services, who each have separate time frames which can result in an experience of extreme
compression to begin with, followed by a gradual decompression of their timescape based on
their movement through services. Decisions are made about the person, with some input from
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them, on how quickly they move through each service, but those decisions are not based on a
scale, like the Hamilton Rating Scale for Depression. Instead these decisions are based on the
service user’s history, notes, practitioner experience, and pressure from senior managers,
which can leave the service user wondering why they are not being listened to or receiving the
help they feel they need. For example:

Cameron: Why do you think they don’t listen to you?

Miles: I don’t know, I really don’t know, it is a question. I think it’s easier for
them to have someone who is ill and functioning well outside, than in a hospital;
it is less money for them, I don’t know, it’s less work for them.

Miles highlighted two separate points in the above quote which are worth expanding on. One
is that it is cost effective to have someone who is ill and functioning well outside the hospital,
and the second is that it is less work for the mental health services. If we return to Harvey and
time-space compression for a moment, he claimed that “stress makes it more difficult to react
in an accurate way to an event” (1989:306). He went on to argue that “reality gets created
rather than interpreted under conditions of stress and time-space compression” (Harvey,
1989:306). The Trust creates a situation where the individual can be managed outside of the
hospital safely, because this serves the system’s purpose in saving money. It may not
necessarily be less work for the HTT or CMHT and the service user might not be safe, but it
costs less than the acute ward. The fact that there are no conditions to discharges, no
thresholds other than those the teams insist on, works in the favour of the Trust. They can
expand and contract their capacity to treat service users at will and when necessary to save
money, inventing the conditions for discharge rather than interpreting patient distress. The
experience of this on the ground extends beyond an embodied sense of compression; service
users compress their narratives to fit within the boundaries of the service.

Service User Narrative Compression

The structure of interactions between staff and service users is increasingly formalised, time
managed, and limited (Pilgrim & Ramon, 2009). As a result, the use of time by service users

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must be carefully considered. When a service user on an acute ward is seen by the consultant,
the conversation is ideally about how their experience has been on the ward over that week.
With smoking now banned anywhere on hospital grounds and chronically low staffing levels,
this conversation often becomes a negotiation for increased leave/time to smoke outside,
compressing any talk of their illness into a very short summary. Meetings with CMHTs can
combine a week, two weeks, or even more into a single meeting where the expectation is for
the service user to not only produce an affective and effective narrative for that time, but also
to discuss the social, financial, and housing difficulties they may be having. Service users with
the HTT also experience this compression when seeing team members who have been
allocated more than three visits, a practice which begins to eat into the time spent with each
service user. Team members with more than three visits are less likely to read through
electronic notes, which means that part of the visit is often devoted to the service user giving
the team member a streamlined account of their history. The resulting encounter with service
users produces a dissatisfaction with home treatment but also a deep-seated sense that such
things are inevitable.

From the teams’ perspective, time-space compression affects their ability to develop a strong
rapport, answer questions, adequately prepare for the visit, and engage in meaningful
conversation about symptoms, difficulties, and social issues. From the service users’
perspective, it is very difficult to describe their complex feelings of distress within a short
period. Laura McGrath and Paula Reavey write about time-space dimensions within mental
health services and argue that complex feelings of distress are “experienced over multiple
spaces and time periods and [are] shifting, manifold and at least partially intangible” (2016:62),
adding that it takes time to unravel these feelings. The difficulty in the encounter between
practitioner and service user is distilling this distress and emotion into an efficient (short)
narrative and delivering this (Brown & Tucker, 2010). When service users compress their
narratives, they then expect the team member who is delivered this narrative to listen and
reproduce it in as much detail as possible in their digital notes. Unfortunately, this is not
always the case and there are often multiple layers of compression that are added in this
process. For instance, the consultant, when reviewing service users, is given a further distilled

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version of the notes for the week which informs clinical review decisions. Even though the
HTT takes a more in-depth and considered approach by (re)constructing a formulation of the
service users’ difficulties, time-space compression and its effects on electronic notes still
threaten to disrupt this process.

Digital Compression and Service User Narratives

Electronic notes have become central to community psychiatry as they make it possible to
track every interaction with health services and police (although the delay on police reports is
often four weeks or more) (Bloomfield & McLean, 2003). The electronic note system is, in
theory, a kind of technological panopticon for interactions with the mental health services,
literally providing the mental health practitioner with a central point upon which to view all
the activities of a service user with the services. This is where, as I mentioned in the previous
chapter, the “data will save us” beliefs of senior managers come from; certainly this enormous
amount of data is the key to the acceleration of services and extension of capacity. Hassan
argues, and this is relevant here, that efforts to increase speed and efficiency produce a
reliance on technology that mediates our existence, producing “new ways of thinking and
being that are instrumentalised and goal oriented in the extreme” (2003:136).

In practice, the electronic note system is more a hall of mirrors than panopticon. The difficulty
is, as Eriksen (2001) argues, speed also produces fragmentation; so what does fragmentation
look like in electronic notes? When the data quality is bad, these notes are often populated
with copied and pasted sections from other portions of the notes, misheard responses,
speculative diagnoses, and other “fragmentation” of service user narratives. When data quality
is good, the compression and distillation of narratives often obfuscates important details or
hides them among a wealth of inane daily occurrences, like what the person had for breakfast.
The difficulty is in the reliance on these notes and the tendency to take them as truth, as
service user identities are constructed a priori (before a visit) for practitioners, producing
misunderstandings and frustration. Both Hassan (2009) and Eriksen (2001), in their writing on
speed and efficiency, argue that with such fragmentation and instrumental thinking also comes
a loss of critical thought. Sifting through this data to build a critical understanding of a service

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user is not an efficient process; it is difficult, frustrating, and time consuming. As these services
are pressured into more efficient ways of doing things, the time that is left over for critical
thought and evaluation is shortened. Many service users complained about having to present
ever more concise and abstract versions of their histories. Others complained about having to
constantly correct the electronic records each and every time they encountered a new team
member/service, as is evident in the following example, which played out across a particularly
difficult time for a family.

Marta was a woman in her mid to late 40s who was overweight and worked a low paying job
with her husband to provide for two daughters, one of whom had just finished university and
was getting married. She attended her GP 17 times in 6 months, suffering from near constant
stomach pains and urinary tract infections, during which the GP failed to diagnose her
pregnancy. She later gave birth unexpectedly on the toilet in her own home. The electronic
notes in the report made by the ambulance that was called for Marta and her new son
mistakenly said she had given birth on a public toilet. This prompted several investigations
while she was in the hospital with her son in an incubator, creating a constant flow of police
and Child and Youth Protective Services (CYPS) in and out of her home and hospital room.
The family felt as though they were tossed from one service to another in rapid progression,
while being subjected to threats and coercion from many of those services. The family
inquired as to how their GP had missed such a diagnosis, receiving a letter from the Trust
stating that there was “a difference in the recollection of events” and that the electronic notes
were not capable of telling a story that could be investigated. This left them with no
confidence in the system at all.

When Marta was transferred to the HTT, the family felt like they were struggling to be
heard. Marta had been released too soon from home treatment in their opinion and many of
the visits were too short, too focused on medication, and lacked any serious input by the
family. They explained to me that Marta tended toward agreeing with people and tried not to
make a fuss, which left her family to raise issues they saw on a regular basis. Some of the
nurses who had longer visits were effective but, overall, the family felt they were still fighting

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against “some serious misinformation”. The family thought the team saw their father as hostile
(they did); they thought he was seen that way because he was Egyptian and fell under the
stereotype of abusive Arab Muslims who beat their wives (this was not the team’s belief). The
father was neither Muslim nor angry; he was merely loud and assertive. The treatment they
received pressurised the situation leading them to complain that the HTT needed to be more
patient and understanding. One nurse threatened to send Marta to the hospital if she did not
see the team in the living room. This led Marta to fret over being sent to the hospital, which
also fed into her false belief that they would take her newborn son away.

Marta and her family felt the pressure acutely; they constantly had to correct the record as the
electronic notes persisted in their fragmented form. The speed at which they were bounced
through the system contributed to a sense that no one listened, and that they were treating an
invented issue (public bathroom, Muslim stereotype) as opposed to interpreting the real
situation. The team interpreted this pressure as the father being a disruptive force within
treatment and so acted to isolate him from Marta during home visits. One team member
would talk to the father in a separate room while the other talked to Marta. The family was
upset because they felt, after looking at discharge summaries from the other services that were
littered with mistakes and inaccuracies, that it did not matter what they told the HTT: “either
way they will write something bad”. The problem the family had was one of money, debt, and
the child care needs for a newborn—all things that could not be addressed by the team. The
family turned not to the state for help but to their friends and relatives who had lent them
money and helped them stay afloat before. I spoke to the family for nearly two hours and
following this, the team noticed a positive difference in their relationship with the family. I can
only speculate that they needed someone to sit down with them and listen to their story,
uncompressed and without judgement.

The pressure experienced by the family and the compression of their narrative did not end up
creating direct or physical confrontation with the services. Instead it revealed that there were
clearly side effects to speed that shape the experiences of service users in negative ways. In
the final two subsections I will take a closer look at these side effects of speed. I will begin by

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looking at abbreviated thinking and how it affects the experience of mental health services for
black people. The second side effect I will examine is a devaluation of the self that is a result
of the lack of an investment of time and resources in their care.

The Side Effects of Speed: Race and Ethnicity and Abbreviated Thinking

Mental health is really a build-up of un-coped-with stresses that build up all the time and it’s
really an explosion and the mind does not know how to cope with and deal with the stress.

-Young Black Male Participant

This is a system and, you know, it works against you, it will work against you, there’s no doubt
about that.

– Black British Mental Health Professional talking about Young Black British
Men

The service user above described his mental health as stress that builds to an explosion. He
followed that up with talking about finding a way to decompress. He told me about how many
of the inpatient staff see his expression of stress through physical activity as aggressive and at
times violent. Inside the ward, the focus on short time frames, rapid treatment, and reduced
staffing levels creates compressed service user narratives, misunderstandings, and frustration
that can further pressurise the environment. The scarcity of time on the ward, in part due to
the focus on discharge, process, and paperwork, creates a system where any aggression is
immediately met with restraint, seclusion, or sedation (chemical restraint). These reactions to
aggression are thought to be a more efficient use of time than de-escalation because it saves
time in the long run if de-escalation fails. This is a kind of abbreviated thinking that comes
from a focus on speed which, I contend in this section, is inextricably tied up with race,
ethnicity, and institutional racism.

In the following section, I will be looking specifically at the experience of young black men
and, to a lesser extent, black women within mental health services. Many of the things in this
section might not appear as blatant racism—they are certainly things that can and do happen

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to white people. That being said, black service users are nearly three times more likely to be
compulsorily admitted than white service users (Weich et al., 2017). The black community is
also “less likely to be diagnosed with mild to moderate mental health conditions” (Grey et al.,
2013:148) and more likely to enter into the system via the police (Lawlor et al., 2012). Though
the experiences that they face might not be classed outright as racist, their over representation
within the mental health system means that they are exposed far more often to this than any
other group of service users. How over represented are they?

Whilst 26% of people in Lambeth identify as Black African or Caribbean, 50%

of Lambeth residents in high secure and 67% in low and medium secure
psychiatric detention are from these groups. This is not solely a Lambeth
phenomenon and nationally black men are 17 times more likely to be diagnosed
with a serious mental health illness than their white counterparts (Lambeth
Black Health and Wellbeing Commission, 2014:4)

Why does this happen? There are several answers to this question but there seems to be an
erroneous link between being black, aggression, and severe mental illness, one that Johnathan
Metzl (2009) has explored in America. Metzl examined the transformation of schizophrenia
from a white, middle-class disease in the pre-civil rights movement to the slow racialisation of
the disorder post-civil rights movement. Specifically, he looked at how “anxieties about racial
difference shape diagnostic criteria, health-care policies, medical and popular attitudes about
mentally ill persons, the structures of treatment facilities, and, ultimately, the conversations
that take place there within” (Ibid:xi). What he found was a manufactured relationship
between aggression and schizophrenia that racialised the disorder as one that came to
represent a racial stereotype of violent and disobedient black Americans who must be “crazy”
to subvert the general order of things. Aggression was eventually dropped from the diagnosis
but the racialised stigma around schizophrenia remained. Segregation and the civil rights
movement of course was not an issue in Britain; however, institutional racism is a problem in
Britain and in British psychiatry (Macpherson, 1999; K. McKenzie, 1999; K. McKenzie &
Bhui, 2007; Sashidharan & Francis, 1999), and is an ongoing concern for the Royal College of
Psychiatrists (2018).

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So how does this racialised notion of aggression fit into a British system where overtly racist
practices are mostly a thing of the past? The answer is through the stereotype of “big, black,
and dangerous” which is so well established in British psychiatry that it was the subtitle of a
report into the death of Orville Blackwood, a 31-year-old black British man in Broadmoor35
(Crichton, 1994; Keating, 2016; Prins, 1993). Blackwood’s death is reported below.

On 28 August the ward doctor prepared to review Blackwood in his side room.
Blackwood was quietly lying on his bed [and had been for 5 hours] when the
doctor entered into his room, allegedly without a knock or warning; there were
nurses outside should he become violent. Blackwood allegedly tried to punch
the doctor and was restrained. The doctor decided to administer Sparine 150
mg [three times the recommended dose] and Modecate 150 mg [twice the
recommended dose] intramuscularly. The staff left the room after the
administration of injections, but soon observed from outside that Blackwood
had stopped breathing. Cardiopulmonary resuscitation was unsuccessful.
(Crichton, 1994:236)

This particular incident is important as the investigation accused the staff of jumping to
sedation too quickly and not using other methods to de-escalate; in other words they were
accused of abbreviated thinking. The report’s author Prins described “the staff‘s constant
expectation that the patients will erupt into violence” and deplored “their tendency to react to
a patient’s expression of dissatisfaction in a reflex way with an extraordinary show of force”
(Lipsedge, 1994:15). The racialised stereotype of “big, black, and dangerous” is reinforced by
Lambeth and Brixton’s representation in the media as violent places, and black youth from
Brixton represented as violent, criminal, and overtly sexual (Alexander, 1996; Back, 1996;
Hall, 2003; Howarth, 2002). A lack of time, a disruptive and pressured environment, the
stereotype of “big, black, and dangerous”, and other factors—all combine to manufacture
aggression from the gaze of ward staff where there may be no aggression at all. I asked one
young black man how he would like to be treated by staff.

35
The subtitle was added to the report because Blackwood was consistently referred to by nurses in the inquiry
as “big, black and dangerous”.

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 I don’t know, to be honest with you. Fairly. Fairly. If I am not being aggressive
or showing the sounds of aggression or things like that and I’m not shouting or
so, at you or so, don’t shout at me or treat me or talk to me in a certain way, or
talk down to me because you’re in a certain position. I’ve heard some staff say
some horrible stuff in the past, but I’ve kind of moved past that now. I just look
at it now that staff are just people in general. I think some staff members make
the patients more ill than well… being on the ward for so long around the same
people and the shouting and the raging and stuff like that, it is quite stressful
and certain behaviour – certain times you’d adapt to that sort of behaviour and
your body will change. I think sometimes the wards will make you more iller
than you actually need to be as well. It’s not really a nice place to be at, but it is
a place of safety for the patient because the patients are the ones at risk really.

Here the young man recounted being treated as if he was aggressive without actually being
aggressive and linked this to a degradation in his own mental health. He mentioned above that
at certain times “you’d adapt to that sort of behaviour”. This is an example of adapting to a
timescape but also of adapting to a way of being treated that is incredibly difficult to deal with.
Other service users like Malcom were not able to adapt to this behaviour and instead met the
aggression showed to them by ward staff with aggression. Malcom only had fragments of
memories from his time on the ward; he remembered “meeting aggression with aggression”.
He related this to how he would deal with this type of aggression being directed at him in the
street. He ended up being sent to a PICU ward. When he returned from the PICU to the
ward he had previously been on, he remembered the female staff not wanting to look at him
and the male staff being very standoffish. Placed in these situations, it is easy to see how a stay
on the ward can feel like incarceration, especially if it appears staff are not interested in the
reasons why they are angry, upset, or agitated.

Coming out of the wards to home treatment can also be quite distressing for those who
experience the punitive side of the wards, as they discover bruises, cuts and scrapes, sore
muscles, and injuries they don’t remember. As more black men are restrained on wards this
becomes a common part of their experience, building frustration with the system and a fear of
seeking help. Which only makes their presentation more acute, raising the risk of exactly the
type of behaviour service users and staff fear (Keating & Robertson, 2004; Keating et al.,
2002).

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After Malcom was released from the ward, I sat with him and a team member who was in a
rush. I watched as the team member interrupted Malcom by speaking over him. Malcom
instantly reacted, getting out of his chair, breathing heavily, and balling his fists. He was
frustrated the team member had spoken over him. Here Malcom was reacting to a pattern of
behaviour which he had experienced in the wards, where he was spoken over and his needs
were not cared for. He saw the team member as not showing him the respect that he deserved
in his own house, reacting in a way that was controlled but left the team member visibly
shaken and questioning my choice to stay behind to interview Malcom. The team member
saw the interaction as Malcom getting angry because he tended towards being aggressive. He
did not realise that he had spoken over him or that this would cause offence. This is just part
of the daily rush, jumping to the assumption that Malcom was aggressive. Reflecting on
whether one’s own behaviour could be the cause is an example of abbreviated thinking—one
that originates from the need to move visits along because time is short. It is difficult to be
reflexive, to have time for critical thought in a system that is focused on throughput (Craig,
2016). Perhaps, to paraphrase Metzl, the question the mental health system should be asking
is: “what mechanisms exist for defining what is not aggression, in addition to defining what is?”
(2009:206). For the team member, this was a “quick visit” to drop me off and check on
Malcom, but speed creates an experience where only the most basic aspects of home
treatment (such as dropping off medication) have been satisfied and the person being visited is
left wanting.

The Side Effects of Speed: Devaluing the Self

Some people come in and they’re just like “what medication are you on? What do you need?”
and they just leave it and go. I don’t know their name, I don’t know who they are. They aren’t
going to stop and have a conversation. I’ve even had people give me medication out on the
street, which I wasn’t – you know, it made me feel a bit uneasy. Just for quickness for them,
you know, “I won’t come in”, you know, and they’ve just caught me taking the dog out quickly
and “I won’t come in but here’s your tablets” and just dishing them out outside.

-Kate

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Does anyone have time? is a question that Kate, the person I interviewed above was asking,
after repeatedly getting “quick visits” that left her feeling as though she was a bother to the
team. Other people being treated by the HTT have found themselves asking similar
questions. Do these people (staff) hate me? Does anyone listen to me? Do these people care
about me? This devaluation of self emerges from the effects of resource scarcity and trust
changes. The difficulty is that persons who suffer from mental health difficulties already feel a
sense of othering and devaluation from the stigma they face every day. This only acts as a
reinforcement of that. The fact that the government continues to claim that they are investing
in mental health and yet nothing gets better produces an affect. The feeling of not being
listened to is a common theme that emerges, something that Diane, a middle-aged black
woman, drew as a thread through her experiences:

that’s the story of my life though isn’t it, I mean no one listens. I mean, not only
just me, but I feel in life people just want to just get on with it. Life is hard. Life
is hard. You know, why do you think I’m using humour to cope, because why
am I going to take myself too seriously? Why should I? What makes me so
better than everybody else? I mean they’re [inpatient staff] treating everybody
else the same. That’s the truth, it’s not that they hate me, so much that they are
treating me this way. (muffled) I’m not anyone… it’s quiet sad too because, the
truth is, we need – a lot of people need their help. Like I said when I was at
Triage, a lot of these patients needed their help and support, never got it, no
one listened, and they didn’t listen to me either.

Diane spoke here of feeling like no one cared, no one listened to her, it had always been like
this for her even before her illness. Here she was saying that it was not that the ward staff
hated her, but that the way they treated her made her feel “lost” because she was not being
listened to, she was not being treated like a person. Her experience here reinforced her feeling
of isolation, separation, and insecurity. Home treatment was the first time she was listened to
by mental health practitioners, but she still faced coercion from the team. She was told that
home treatment was not an option, even though she was not under section. Diane had an
attitude that was to “just get on with it”, a resignation that the system was not there to help
her, part of which came from her experience of being sectioned.

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Service users understand the financial and other constraints that services like the HTT are
under. There is an abundance of information on the difficulties and financial constraints of
NHS Trusts that can be found on social media, news media, or from other service users, and
even mental health practitioners. An unexpected side effect of government austerity
programmes that have led to substantial changes within NHS trusts is a devaluation of the self.
For example, if my distress is not worth the concern or money and the struggle to get the right
services is this difficult, then the value of my humanity has not been confirmed. This leaves
service users in a position that makes it hard for them to account for why the service should
even treat them. If there are people who are more ill, they are the ones who really need the
service, not them. This is despite their meeting the HTT threshold for admission.

The fact that they [the HTT] come initially every day and then every other
day, you know, I appreciate that they do that because I might not be as sick as
some other people, some people who live on their own…. I think they are a
very good support group, but I think sometimes they try and rush you to get
yourself back out there. I know in this society, and in this day and age, you’ve
got to be practical and they can only stay with you for X amount of time
because there’s lots of people that need the service, and with cuts and things…
On the whole the actual team are fantastic, on the whole, you know. But I
know, I understand it’s because of cuts and changes, you know, and NHS, you
know, we are very lucky to have this service at all, other places you wouldn’t
get this… the fact that we have it at all is amazing.

Kate here spoke about how she appreciated having home treatment because she thought that
she may not have been as sick as other people who lived alone and needed the team. She
admitted that they had their faults but on the whole the team was “fantastic”. All of this was
underwritten by a knowledge that the service was underfunded and that cuts threatened the
way that it engaged with her. The rhetoric that surrounds Austerity, the throwbacks to
collective suffering and rationing, produces a situation where an individual devalues their own
distress in order to fall in line with this austere logic. This, I believe, keeps people from
utilising the services to the extent they need and allows for speed to take control.

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Why chase a system that clearly does not want you as a service user and moves you as quickly
as they can to another service? The cuts themselves are a symbolic admission that lines up
with depressive and other symptoms of illness that presents a world view to service users
where they are devalued as unproductive citizens. This is perhaps unsurprising based on the
rhetoric that surrounds benefits and service use which I will touch on in the following chapter.
Contrary to rhetoric that forms these beliefs, it is common for many service users to delay
until the very last moments to apply for any type of benefits, draining reserves of savings and
money first before actively engaging in the benefits system. Earlier engagement would have
saved considerable money and in many cases made things financially easier. I believe this is a
way of distancing themselves from the “unproductive and undeserving poor”. It also allows
service users to distance themselves from feeling as though their illness has resulted in a total
loss of productivity.

With the HTT, the service user is looking for the team to be familiar with their illness and
experience and to convey that through interactions with them. This familiarity confirms their
existence in way that being on the ward often fails to do. Part of why the HTT is good at
doing this is because many service users are very socially isolated and actively trying to
(re)engage the service user with the community is part of the treatment strategy of the HTT.
For the service user, when home treatment is done right, the experience is one that (re)affirms
their importance and their place in the world. When HTT suffers from time space
compression, it often falls into the same difficulties as other services. That being said, the
environment which produces the experience of austerity goes beyond the services that people
interact with and spreads into their community. The problem is that many of the aspects that
can create emergent problems in the lives of service users are out in the community and
reinforce notions that the service user is a burden on society and on services, and should either
be productive or work their way to productivity. There is a “landscape of distress” that works
to recreate negative ideas about self-worth and reinforce the affect generated by treatment
within and without the mental health system.

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Chapter 9: A Landscape of Distress: Austerity in the Community

The focus of the previous chapter was the individual experience of service users of the home
treatment team. This chapter will broaden that focus by examining how service users
experience the landscape of Lambeth and its effect on their mental health. In doing so, I will
explore a landscape that has been deeply affected by austerity policies, and one that has taken
a larger and more problematic role in the lives of service users of the HTT. I chose to use the
term “landscape” to bring to life the relation that service users have (or do not have) with the
natural, built, social, and symbolic aspects of their community (Gesler, 1992). These four
aspects form the basis of a therapeutic landscape, a concept first introduced by Wilbert Gesler
and one on which I will base the development of a new concept (1992). The concept of a
therapeutic landscape gives me a way to focus in on aspects of Lambeth that have an effect on
mental health. It also provides a framework from which I can stitch together the disparate
experiences of austerity into a topography of affect. I will, therefore, argue in this chapter that
the effect of austerity policies on the landscape of Lambeth has reconfigured the service users’
relation to their government, home, community, and workplace, creating a landscape of
distress.

In differentiating my concept from a therapeutic landscape, I take inspiration from an earlier

and excellent study of mental health and landscape by Michael Dear and Jennifer Wolch,
published as Landscapes of Despair: From Deinstitutionalisation to Homelessness in 1987. Their study
warned that the tendency towards creating “service-dependent ghettos” had the potential to
create a “landscape of despair” in the future. They described such a landscape of despair as
follows:

The perfect metaphor for this terrain is provided by the homeless who nightly
populate the beaches of Santa Monica and Venice, California. They sleep next
to the ocean at the continent's edge, a little distance from a tide that could
sweep them away. This portrait of the landscape of despair presages the
collapse of the human-service system and an abandonment of those in need.

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 The lucky and resourceful who manage to survive hang on by their fingernails
at the edge of society (Dear & Wolch, 1987:254).

There has been no collapse of the human services in South London; indeed compared to
1980s California, the services available are of a much higher standard and stretch much further
into the community. Lambeth is still a far way off from a “landscape of despair” and the
abandonment of those in need; however the landscape I have observed in my work is one that
engenders distress and ought to be engaged with as a whole. Thus, I am introducing a new
term, namely a “landscape of distress”, to describe and bring to the fore the nexus between the
individual and austerity. I will investigate how this relationship influences the individual’s
interface with the home, community, and employment. At the end of this chapter, a clear
picture of the landscape of distress that exists in Lambeth should be apparent through
examples from my fieldwork, government documents, and interviews with residents and HTT
members. To begin to examine the landscape of distress, I need to first introduce therapeutic
landscapes.

The concept of a therapeutic landscape originates with health geography and was developed
by Gesler and extended by scholars in geography, sociology, and anthropology (Curtis, 2010;
Gesler, 1992; A. Williams, 1998; 1999; 2007; Winchester & McGrath, 2017) to explore “how
various environments affect the experience of illness and health in specific places” (Baer &
Gesler, 2004:406). Gesler identified places that had a long history of being therapeutic, due in
part to features of their landscape. These included, for instance, the healing spring in Lourdes,
France (Gesler, 1996) and the hot springs in Bath, UK (Gesler, 1998). Landscapes used in this
way refer to much more than just what is part of the natural environment. Therapeutic
landscapes include the natural, built, symbolic, and social environments, and spread beyond
just understanding places of healing. They are also more than an objective reality and,
therefore, are not experienced in the same way by everyone; instead, these landscapes are
very much tied to subjective understanding and lived experience, and are often imbricated
with one another (Conradson, 2005; Gold & Clapp, 2011; MacKian, 2008; Thorsen, 2015).
Similarly, the landscape that I am going to describe in this chapter is experienced rather
differently by different residents of Lambeth. For instance, those who have access to
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resources and support systems are able to neutralise some of the features of the landscape; just
as a mountain climber, aided by ropes and climbing gear, can choose his ascent to avoid
difficult areas. Those who rely on support from the state are increasingly forced to climb the
mountain without equipment. Differential access to services and opportunities within Lambeth
create measurably different experiences of the landscape and, in relation to this, differential
experiences of illness.

In the past, therapeutic landscapes have been criticised for focusing only on the health effects
of landscapes and not on their potential for negative effects (Wilson, 2001). Since that time,
there has been a growth of literature that acknowledges and utilises therapeutic landscapes to
examine the ill effects that landscapes can have on an individual (Baer & Gesler, 2004; Gesler
& Curtis, 2007; Wakefield & McMullan, 2005; A. Williams, 2002). I plan to go much further
than this literature, while following the features it identifies as affecting health which include
the “natural, built, symbolic and social environments”. I will exclude the natural features of
Lambeth, which have been mostly covered with concrete, pavement, and other structures for
hundreds of years. The built environment of Lambeth will be explored through the often
crumbling/damp/mouldy homes of service users and the council estates—many of which face
demolition and “regeneration”—that they live in. I also explore how service users experience
this built environment on the level of the individual home and the community. The symbolic
environment is examined by analysing the rhetoric deployed by the government around
benefits. The landscape of distress itself is experienced differently, based on one’s access to
resources, and disproportionately, because of racism and prejudice.36 Finally, I look at the
social landscape of precarious employment and how this can make the landscape of distress
stretch much further than those living in poverty.

36
Here it is important to note that although landscapes often refer to a physical environment, there are aspects of
therapeutic landscapes that are not physical, and go beyond the physical, the symbolic, and social aspects in
particular, and thus it should not be expected that my exploration of the landscape of distress will be grounded in
the physical features of Lambeth.

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By laying out this framework based on the therapeutic landscape concept, I have tried to
examine the aspects of the landscape in South London that can have a deleterious effect on
mental health. I cannot, however, claim that this is a reality for all of the residents of Lambeth
or even for all of the service users in Lambeth. The participants of my research had much
smaller (or larger) areas that they would define as their individual landscape, many which did
not include all the aspects that will be discussed in this chapter. For instance, due to social
isolation, some of these individuals experienced a landscape that could be as small as their own
flat, a few offices, and the bus. Conversely the social environment and effects of austerity can
also be felt on a personal, community, city, and national level. In the next section, I will
examine how a symbolic landscape was created by the government to sell austerity to the
general public, one that fell back on the old trope of the deserving and undeserving poor.

The “Age of Austerity”, Workfare, and the Individual

“They give with this hand, they take with the other”.

– Service User

The “age of austerity”, a term Prime Minister David Cameron (2009) used during his first
election campaign, heralded a tumultuous period that forced numerous people into privation
(Alston, 2018). The austerity programmes that he later enacted accelerated the already
chronic underfunding present within the mental health system. They also had a ripple effect
on the mental health of millions through changes and cuts to the welfare system. The
attention I want to draw here is to the way that consent was sought from the public for
austerity (Clarke & Newman, 2012). In seeking consent, the government had to realign itself
ideologically, to move blame from an economic problem originating in the banking sector to a
political one with its origin along party lines: “a reworking that has focused on the unwieldy
and expensive welfare state and public sector, rather than high risk strategies of banks, as the
root cause of the crisis” (Clarke & Newman, 2012:300). The rhetoric from the government
about the financial crisis shifted slowly from “predatory lenders” and “out-of-control

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capitalism” to “ballooning government debt” and a deficit of character in workless benefits
claimants (Clarke & Newman, 2012). This repositioned benefits claimants, including those
who were formerly considered worthy of support such as the disabled, as part of the problem
(Briant et al., 2011).

The coalition government positioned their arguments for austerity as morally right, claiming
that “ending Britain’s welfare culture is a moral duty” (Conservative Party, 2008). To make
austerity more palatable, they drew upon the familiar and nostalgic tropes of collective
suffering and rationing from the post war years (Hinton & Redclift, 2009; MacLeavy, 2011).
The government also argued that it was unfair to those who worked diligently to better
themselves while others received benefits while living “unproductive” lives (Clarke &
Newman, 2012; Pantazis, 2015). This argument recast those receiving benefits in the
Malthusian terms of deserving and undeserving poor (Harkins & Lugo-Ocando, 2016),
reviving defunct views that those at the bottom rungs of society were either worthy of support
and productive or they were morally deficient, lazy, and undeserving (Morris, 2016).
Ironically, these austerity measures took the form of a further development to the workfare
(rather than welfare) system and hit those in privation the hardest, raising inequality and
resulting in anything but collective suffering or solidarity among Britons (Alston, 2018).

The government’s framing of the economic crisis ultimately shifted the narrative towards a
rhetoric of Britain as a “broken society” (BBC, 2011; Helm, 2007) that needed to focus on
individual values, obscuring the effects of greater economic currents (Finlayson, 2010). British
public opinion has followed this shift as “62 per cent of the British population now believe that
out-of-work benefits are too generous and promote the ‘dependency culture’ that is now seen
to exist in the UK” (Deeming, 2015:867). This offered the government a clear path to
intervene in the lives of those on benefits in a new way, speeding up what was a longer term
shift away from the “welfare state” and towards a new “workfare state” (Deeming, 2015).
Workfare shifts the responsibility from the state to the individual, creating conditions that the
state lays out that must be met to continue to claim welfare benefits. This is meant “not simply
[to] reduce unemployment but also tackle the wider cultural problem of ‘worklessness’”

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(Deeming, 2015:864). Some of these activities that must be completed are directed at
psychologically molding work seekers’ behaviour into the positive affect needed for the
temporary or unpaid labour which is a condition for continued benefits (Friedli & Stearn,
2015). Christopher Deeming sums up the new UK workfare regime as follows:

To maintain eligibility to benefit support, jobseekers must actively look for paid
employment or face benefit sanctions; they must take up any offer of paid
employment or face sanctions; and they must undertake all specified work
preparation activities demanded or face sanctions. If conditions are not met,
claimants can now find their benefits suspended for up to three years.
(2015:864-865)

Here workfare policies are directed towards “encouraging” individual responsibility but in
effect they recreate an old dichotomy between the deserving and undeserving poor which acts
to reinforce the symbolic position the government has taken on claimants. Those who are
involved in looking for work (which often includes unpaid work or temporary contracts) are
productive and worth supporting, while those who do not look for work are lazy,
unproductive, and should be forced off benefits or into work (Friedli & Stearn, 2015). In
creating such a dichotomy, the larger socio-economic trends that produce precarious work and
other conditions that work to keep people in poverty and create a cycle of privation are simply
plastered over (Finlayson, 2010). This creates an experience of failure for those on welfare that
individualises larger socio-economic problems. When they cannot find full-time paid work, it
is not a socio-economic problem but a problem of their own making—they are not working
hard enough. The rhetoric and workfare programmes have produced a landscape where
economic instability is blamed on the individual and this has now been extended to those who
are suffering from mental health issues.

The dichotomy between the deserving and undeserving poor extends to those with mental
health difficulties through workfare programmes. Mental health difficulties and disability
claims can insulate an individual from the most intensive programmes for short periods, but
individuals are still screened through Work Capability Assessments (WCA) every two years.
The screening, carried out by private contractors separates out those who are “capable” of

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working from those who are not. Those found fit for work are moved into the workfare
programmes with the goal of obtaining full-time work with punitive sanctions for lack of work
determined on a case-by-case basis. However, many who do actually face significant barriers
to work fail these assessments, leaving them to appeal the findings. More than half of these
appeals are successful (Stone, 2016).

The process from assessment to decision can be distressing for the individual and has been
linked to the development of acute mental health crises. For instance, a report has established
a strong independent association between the WCA and an increase in “suicides, self reported
mental health problems and antidepressant prescribing” (Barr et al., 2015:339). The policies
that have driven workfare, such as the WCA, have a psychic life (Mills, 2017), a term which
originates with Judith Butler’s “psychic life of power” and is made relevant to the UK by
Anne-Marie Fortier’s “psychic life of policy” (J. Butler, 1997; Fortier, 2016). Fortier writes
about how “an enduring feature of the citizen-state relationship is anxiety”, something which
the workfare state seems to construct with its reliance on conditionality (2016:6). Fortier
writes about the citizenship process in the UK that locks its applicants into a relationship with
the state that revolves around anxiety. In Fortier’s case, it is the anxiety of being screened out
as a fraudulent claim or unwanted citizen who is unable to meet the demands of citizenship.

This citizenship process is strikingly similar to the anxiety of undergoing a WCA. The anxiety
generated by the anticipation of screening shapes the psychic life of the individual and can
initiate a relapse. Take, for instance, William, who spent months leading up to the assessment
stockpiling food, preparing for the worst, and fixating on the WCA. It was during this time
that I first met him. William told me that he had to travel hours away from his home for the
WCA, only to find that the nurse who was assessing him did not know what lithium was used
for. He was judged as fit for work based on his ability to show up to the meeting on time. He
then appealed the ruling and again ended up with home treatment in crisis. After his appeal
was denied, his condition deteriorated quite dramatically, ending with him in a Psychiatric
Intensive Care Unit (PICU). The HTT saw countless other service users who were also in the
midst of the assessment process or on appeal and in crisis.

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Successive governments, from “New Labour” to the present Conservative government, have
all pushed forward the idea that there are people receiving disability benefits who are either
not disabled or would be served better if they were employed (Patrick et al., 2011). To
accomplish this, the system was reworked to make receipt of benefits conditional based on the
completion of activities specified by case workers, with sanctions added if those conditions are
not met. The conditions that need to be met to receive benefits have been intensified over
time and the sanctions have increased in use and severity. The conditions are considered by
the Department for Work and Pensions to “help the claimant understand more about their
career options and skills, increase confidence, and provide valuable experience that makes
them more attractive to an employer”(2011:8).

The ESRC funded Welfare Conditionality project found that conditionality was ineffective at
moving people into paid labour or progressing people within paid labour (Dwyer, 2018).
Further to this, for a “substantial minority” of claimants, conditionality lead to increased
poverty, homelessness, exacerbated ill health, and “survival crime”, and led to disengagement
from the welfare system (Dwyer, 2018). The typical pattern within welfare conditionality
found by these researchers over a two-year period were “recurrent movements between one
short-term, low-paid, insecure job and another; interspersed with periods when people
returned to unemployment or incapacity benefits, as contracts ended or illness/impairment
intervened” (Dwyer, 2018:2). Ben Geiger, in his review of international and UK, finds
evidence for sanctions and conditionality in the management of disability benefit claimants
that “sanctioning in the absence of other support can lead to destitution, and that
conditionality can negatively influence mental health” (2017:123). Researchers in Scotland
found that, for many, work capability assessments caused a deterioration in mental health from
which they did not recover (Marks et al., 2017). The number of people who have attempted
suicide in their lifetime who are on disability benefits has more than doubled from 21% to 43%
since 2008 and the introduction of the WCA (Bulman & Polianskaya, 2017).

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For those who are disabled or struggling with mental health issues, the WCA and
conditionality communicates to them that they are not worthy of the support they received
before. With the massive increase in discourse around the deserving poor and undeserving
poor (Baumberg Geiger et al., 2012), the suspicion cast on them by the welfare changes can
leave them only to think that they are scroungers. For example, a woman was asked why she
had not committed suicide yet in a Work Capability Assessment. She told the Guardian,
“When someone asks you to defend your reasons for staying alive, it puts thoughts in your
head which shouldn’t be there … You wonder if others also question why you haven’t killed
yourself. You think about whether there is a duty to die” (Ryan, 2017). Asking whether there
is a duty to die reveals the pressure of a system that is not able to find a way to value those
who are not yet, or cannot be, productive within the limitations of a capitalist economy. The
state has shaped the benefits claimant into a symbol of economic, social, and individual failure
and failed to provide them with an effective way to escape this.

Service users, like William, live out the impact of austerity programmes like workfare. Their
lives are increasingly punctuated by anxiety-inducing moments when they need to pass as
disabled/disordered or be moved into workfare programmes. The consequences for missing a
meeting or assessment, or failing to follow the directions are severe and include sanctions (no
benefits for 1-26 weeks) on those benefits. Everyone who is disabled and cannot work
undergoes this assessment every two years, regardless of their disability. This creates a
constant sense of conditionality throughout the life of someone who is disabled or on benefits,
making recovery from mental illness difficult and potentially generating depression and
anxiety (Barr et al., 2015; Dwyer et al., 2016; Geiger, 2017; Hale, 2014; McNeill et al., 2017;
Mehta, 2018).

Austerity policies, including those of workfare, fade into the background noise of service user
lives, reappearing seemingly at random. Esther Hitchen writes about how Austerity generates
atmospheres that are lived with/in, creating an affective experience (2016). For Hitchen, “the
concept of atmosphere enables us to attune to the ambiguous presence of austerity and
therefore to explore the ways in which individuals experience austerity through fluctuating,

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non-coherent affective relations that come to shape how they feel and act throughout the
everyday” (2016:103). For example, one of my participants who could not read had to wait for
someone to read her mail. In the recent past, she received a brown envelope from the DWP
that notified her of an overpayment of benefits which led to a significant reduction in her
benefits. This reduction in benefits made it more difficult for her to live. From that point on,
an atmosphere of anxiety would descend on her when she received a brown envelope, leaving
her to ruminate over its contents until a friend or health practitioner could read it to her. She
feared being overpaid or sanctioned and told me in an interview, “They give with this hand,
they take with the other”.

Austerity as an economic policy is a symbolic singling out of those in privation. There is a

clear effort to produce an anxiety within the lives of those on benefits through conditionality,
which may be designed as a punitive way to push people into work or off benefits but it often
pushes them over the edge instead. For one fifth of the UK population who live in poverty
and the 1.5 million who are destitute, the workfare system and conditionality engenders
distress and constructs a relationship with the state whereby the socio-economic currents, the
ebb and flow of job markets, are ignored and the sole responsibility is placed on the individual
(Alston, 2018). This constructs an anxiety and affective experience that only compounds
when the environment in which individuals live resembles the conditionality that emerges
through the benefits system. The impact of austerity can be felt in the landscape of Lambeth
and can be narrated through participants in my field work.

A Distressing Home
To explore the built environment in Lambeth and how it contributes to the formation of a
landscape of distress, I need to introduce the process of estate regeneration. Estate
regeneration refers to the renovation or demolition of council estates to replace them with
more housing units, most of which will be sold on the open market. There is a pattern to the
regeneration of estates that has a negative impact on the mental health of the estate’s
residents. These estates are being managed into decline and disrepair to create the grounds for
demolition and regeneration. There are promises to replace the council homes with

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“affordable homes” and social housing units but few if any are actually delivered and the cost
of affordable housing is often questionable. By demolishing council estates under the guise of
regeneration, occupants are “decanted” or “evicted” to be rehoused in other boroughs, if they
are rehoused at all. The quality of housing, especially low-income and social housing in
London, is a huge contributor to instability and distress. If there are problems with social
housing, the associations rarely deliver on promises to repair or refit badly neglected units
(ASH, 2018b).

Regeneration of council housing is not as simple or innocuous as tearing down old dilapidated
buildings and providing new social housing and affordable homes in London. From 2012 to
2015, over 50,000 families were shipped out of London boroughs due to cuts to benefits,
regeneration, and other difficulties brought on partly by austerity policies (D. Douglas, 2015).
The current difficulties with London housing were intensified shortly after 1979 when
Margaret Thatcher came to power. She brought in a scheme that would allow current council
tenants to buy their flats at a reduced rate. This “right-to-buy” scheme was combined with
other measures, effectively preventing councils from replacing these properties and thereby
drastically lowering the number of council homes in London (Hodkinson et al., 2013; Jones &
Murie, 2008). With council funding from the central government estimated to drop by 40%
from 2010 levels by 2020, and with an ongoing need to provide more social housing, local
councils have turned to private business to “regenerate” council estates at a profit (Savage,
2018).

This has been supported by an influential report produced by Labour peer Andrew Adonis,
entitled City Villages: More Homes, Better Communities (Adonis & Davies, 2015). This report
argues that the density of London needs to rise as it remains short of its pre-war levels. The
boroughs they identify as needing “densification” are inexplicably the ones that are already the
densest in London, including Lambeth. The reasoning behind this is presumably that these
boroughs (which include South London) have the most council estates (Elmer & Dening,
2016). A recommendation of the report is that council estates are re-categorised as “brownfield
land”. Simon Elmer and Geraldine Dening of Architects for Social Housing (ASH) point out

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that “brownfield land is a term used in town planning to describe former commercial or
industrial land that has become contaminated by chemical or industrial waste, and requires
‘cleaning up’ before being redeveloped” (2016:273). Converting council estates to brownfield
land and opening the way for tearing down the estates in favour of (un)affordable housing and
luxury flats37 is a more forceful gentrification. This forceful gentrification has a clear parallel
with the numerous slum clearances of historical London. Indeed, adding to the symbolism that
the government has played up for benefits changes, council estates are areas commonly
assumed to breed crime, maleficence, and anti-social behaviour. This is despite the targeted
inner London council estates housing more than 1.7 million people, only a small percentage of
whom may be maleficent. For many tenants, council estates provide a much-needed social
solidarity and often have lower crime rates than surrounding areas (ASH, 2017; 2018a;
Beckett, 2016; L. McKenzie, 2015).

Multiple estates within Lambeth and the catchment of the HTT have been subject to
“regeneration schemes” which often result in the majority of council tenants being evicted and
“decanted” out of the area. The process of decanting refers to the practice of councils offering
rental units elsewhere in London or England instead of allowing the council tenants to return
to their properties after the estate regeneration or being housed in different areas of the
borough (Lambeth, 2013). The developers have a responsibility to at least include 35% council
housing on the site of any new development, although there are ways around this (Flynn,
2016). The famous Heygate Estate in Elephant and Castle was redeveloped from 1200 council
estate units to just 79 council estate units (ibid). The developer used a “financial viability
assessment” to prove that by providing the needed council homes, the project would no longer
be financially viable (ibid). This was despite the fact that the financial viability profit margin
was set at 25% and not the average 15% for such builds (ibid). It is clear that the table is tilted
in favour of the developers and council and against the citizens.

37
Although Adonis himself does not advocate for building luxury flats, he is, as an expert in the London housing
crisis, well aware of repeated broken promises to replace social housing once tenants have been decanted. For an
example, see the Heygate Estate and the wonderful breakdown by the 35% Campaign on how a promise to
reprovision 100% of the 1000 council houses became 91 council homes. Affordable housing – broken promises
http://35percent.org/affordable-housing/

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Within South London, there is a clear strategy in place for justifying the regeneration of
council estates. This strategy has been researched by a group called Architects for Social
Housing (ASH), who have identified 237 council estates that have been affected or are
threatened by regeneration (ASH, 2018a). Several of the council estates that have been slated
for regeneration follow a particular pattern that can and did affect the mental health of service
users seen by the HTT. First, the council slowly allows the estate to fall into disrepair. As
estates fall into disrepair, their tenants suffer negative effects to their mental health from the
low quality housing (Evans, 2003; Gifford & Lacombe, 2006; Guite et al., 2006; Harris et al.,
2010; Hopton & Hunt, 1996; Hunt & McKenna, 1992; Liddell & Guiney, 2015; Page, 2002;
Shenassa et al., 2007). In Cressingham Gardens, a quiet, low-crime council estate, “repairs and
maintenance have been neglected by successive Councils giving rise to problems in some
homes such as damp and mould” (Douglas & Parkes, 2016:287). Through a dedicated
campaign, the residents of Cressingham Gardens have so far been able to stave off demolition
through a Judicial Review. Central Hill, another council estate in South London, is slated to
be demolished. Lambeth Council has claimed it is in a state of disrepair with damp, mould,
and other problems for which—like Cressingham Gardens—the residents blame poor
maintenance by the council (Moore, 2016). Neglecting maintenance on council estates;
claiming they are too costly to refurbish and need to be torn down; drawing up plans for
regeneration; consulting tenants and then ignoring tenant concerns or forcing them to choose
between options they do not want; and going ahead with regeneration and using secretive
legal loop holes to avoid replacing social housing are practices that were pioneered on the
Aylesbury estate (Lees, 2013). As Loretta Lees argues, “This is social engineering, social
cleansing, sold as urban renewal/regeneration” (2013:932). With so many council estates being
targeted by this process in South London, it was not surprising that many of my participants
felt the effects of this.

I visited Reagan at her two-bedroom flat on a council estate which was just slated for
demolition and regeneration in early 2018 (Metropolitan, 2017). I interviewed her in her living
room while her three children played in another room. We talked about how she ended up in

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her flat. She told me that she started out with a one-bedroom flat in a notorious council estate.
I asked her what it was like to live there?

What was it like? It was an awful place, it was a kip. You could see through the
next-door neighbours’ wall for crying out loud. If you go down the hall there’s a
massive crack and you’d say something, “Hi” [she mimes waving], “Hi”; and
you’re just like oh my God what is this like. Cause it would be if you walkin
past, obviously it’s a massive hole so I’d just look at her and she’d look at me
and she’d be like that, and I’d be like “hi”. “Oh Christ”; it was a bit annoying,
I’d have to admit. Definitely a horrible place to live in. Plus it was an attic flat as
well so you couldn’t have a double bed and a single cot, it was too small. So in
the end I had to have him in the bedroom and I had my bed in the sitting room
because it was too awkward any other way of doing it. And obviously with
kids, you need more stuff for the kids as well when they’re only babies and
stuff, so I let me give them the whole of the single room and me and David
would just have to take the front room and have it as our front room and our
bedroom, so. Then when I got this place I was chuffed because it looked
massive to me but then that fell to pieces, I had to get environmental health
involved, I had to get social services involved.

As we spoke, she pointed out the damage to the walls in her flat. Hidden behind curtains were
the crumbling walls the council workers did not fix completely. She told me how they painted
over damp from a leak that kept her from using her kitchen for three days. Still, she insisted
that the flat was not bad. The flat did cause difficulties for her and her children’s physical
health. The local school kept a close eye on her kids as they were having difficulty breathing
and were constantly being admitted to the hospital. The school finally had a doctor do a home
visit. Reagan recounted, “He came and did a home visit and said, ‘Oh my god, I can see
exactly why they’re always off school’, he goes, ‘because the damp always affects the elderly
and the young’”. The disrepair and difficulties that Regan had were shared by many of my
participants.

Miles, another participant, told me about his ongoing difficulties in trying to get the mould
repaired in his new-build council flat. He told me that getting his medications right and
balanced was not an issue for him; it was his flat that continually stood as a barrier to his

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recovery. I asked him if his care coordinator would help him with this and his response
detailed the neglect that he experienced and its impact on his mental health.

In a sense, yeah I can speak and see services but in a sense I’ve realised I really
can’t, cause if it was down to them and I followed everything they said so far,
especially with my housing officer, I’d be very ill physically; mainly physically
as well, because of the black mould. I’ve been complaining that there is mould
in the place and there is nothing that has actually been done about it. “It should
be alright, just turn the central heating up”. And what happens when you turn
the central heating up with mould, it makes it actually grow more and release
more spores. So, I ended up buying an air purifier and things like that and, what
do you call it? A dehumidifier, and someone else apart from myself, a family
member had to step in before they actually looked into it. They called the
surveyor to look at the mould and the surveyor said one of the ceilings could
have collapsed.

According to Miles, his flat directly contributed to his relapse and kept him from recovering.
Without help to remedy the mould, Miles found himself having to rely on his family and
friends for help and support. This only built on a previous distrust of services, consolidating
the feeling of not being able to receive the support that he really needed to recover. However,
not every service user experienced their home as wholly good or bad.

When discussing home spaces and mental distress, Ian Tucker and Lesley-Ann Smith bring
up a good point which should be kept in mind here. They state that “what is important is to
analyse the life spaces of service users, and to be open to interpretations that do not simply
reduce reading of such spaces in terms of good or bad mental health” (I. Tucker & Smith,
2014:182). Regan, unlike Miles, did her best to make her flat feel like home, including
changing the paint from magnolia to a shade of red and repainting after the makeshift repairs.
The curtains and paint that hid the work that was haphazardly completed helped her feel at
home again, despite the difficulties that were beneath the surface. The space of the home can
have different effects on physical and mental health than just it being a badly constructed
space; sometimes the service user can struggle with the relation between that particular space
and their mental health issues.

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The Experience of Illness in the Home
Some of the service users I met who heard voices had a spatial relationship with the
experience of hearing those voices. Diane, a service user I interviewed, spoke to me about the
relation between the voices she began hearing nine months previously and her flat of fifteen
years. She told me that she really needed to move from her flat, not just because of the voices
but also because she did not get along with the neighbours she had. Her neighbours made her
feel as though she had no real privacy. She talked about how she could always hear them
slamming doors, and screaming, and shouting all through the night. After this had been going
on for quite a while, she began to hear voices.

The nurse, he was saying that some people just feel that you know the things
that they are saying are really quite distressing, and I thought I was the only
one who felt that way … The worst thing about it, it started off quite nice; they
were very complementary and everything, these spirits. I know you probably
thinking ‘but it’s in your head’. I don’t personally think it is, but um it’s kind of
over the last nine months it’s changed. Because I know they were there before I
felt their presence. I knew there was an entity in my home and I just started
seeing things, and for the life of me I didn’t know what it was. And um, because
they used to say things like (in a soft voice) “Love, Love”, (in a soft feminine
voice) “Hello Love”, “s’cuse me love”, and I’m thinking oh my god what the
hell’s that. You know it was quite scary at first because I’m thinking, I only live
here on my own and these voices are saying “s’cuse me love” or they say “I’m
hungry, I’m hungry”. Ok, you know things like that … I do believe it’s haunted
to be honest.

In the above quote, Diane talks about how the voices, which she told me were rooted in her
home and she did not hear them outside the home. The voices started off as a presence, which
she began to hear, and eventually, the voices began to say distressing things. This, I imagine,
matched her experience of living in the home. It began nicely, then she noticed her
neighbours, and slowly, over time and with confrontation, her home became a negative place
that she wanted to escape. In a way, Diane was haunted both by the noise her neighbours
made and the nieghbours’ presence in her life. She recounted at one point in the interview, “I
don’t really want to talk about her [the neighbour] because I know as soon as I mention her
name it’s like I’m giving her life, you know and for years I just can’t stop talking about this
woman and all the weird things she used to do”. Diane’s experience was of voices that spoke
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to her only in the home and in very particular ways. Other service users I spoke to had
different experiences that were more contextual and embedded within the space of the home.

The way that voices can become embedded or even embodied within a space becomes
apparent with the experiences of Darren. When I spoke to Darren, he had recently started
hearing multiple voices, many of which were people he assumed to be his neighbours, as well
as an authoritative voice. When he was in his flat, the voices focused on the things he was
doing in the flat. For instance, he explained that when he was watching a movie, the voices
told him to turn the volume down because it was annoying the neighbours. He responded by
turning down the movie at loud points and turning it up at quiet points. The voices continued,
claiming that he had installed speakers in the floor that were disturbing the neighbours. Over
time, he began to call the voices the “guilt-o-matic” machine as they were continually saying
things to him that made him feel guilty. He described his interaction with his home as if there
were sensors in his home. When he got up and looked out the blinds, the voices would say,
“oh he’s looking out the blinds again” and when he went to the washroom, they would say,
“oh, he’s going to the washroom again, like a fool”.

They’ve said (the voices) various things like – I’ve got those sensors right in the
corner for security, it’s like an opaque something with a blue light on it; and
when you wave your hand in front of it, the blue light comes on. And there was
talk at one point from the voices that they were using that to spy on me, using
that infrared imaging or something. And then there’s been hidden cameras;
speakers in the vent system because I’ve got one of those vents in my ceiling in
my bathroom.

Darren revealed in this excerpt from an interview with him that his relationship with his voices
was mediated by his experience of the home. In a way, the voices were embodied within the
home through the associations they claimed with the security sensors. It was no doubt a
distressing experience for Darren and one of the main reasons that he regularly tried to leave
his flat and spend as much time walking outside as possible. Granted, he still heard the voices
outside, but he could listen to music and tune them out more effectively. Back on the inside of

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the home, the windows that provided views to the outside became a point of contention with
the voices.

I went through a phase of looking through the blinds a lot, and umm bothered
my partner, and he was like “you look like a nutter, constantly looking through
the blinds, like, stop doing it”, and I got some paranoia about that from that; oh
god the ladies are going to think I’m like this crazy curtain twitcher who’s just
nosing on everyone’s business. And now when I go near the blinds, not so
much now but there was a period where it was like, (mimics a voice he hears of
a snide woman) “he’s looking through the blinds again”. I’d hear that in my
head so it was like the guilt I had being played back in my head, same with the
peephole in the doorway.

The way that Darren navigated space throughout his house and experienced it as mediated by
the voices he heard can be described as “spatialisation of experience” (Tucker, 2010a:526).
Particular aspects of his home space, either imagined or real, played into his experience of the
voices and formed a repetitive pattern becoming in some sense a habit or routine. Service
users who experienced their illness in a way that imbedded itself into the space of the home
had a different relationship with their home, one that could be made even more complex by
the experience of noisy neighbours, mould, or disrepair. Estate regeneration and the managed
decline of council housing can have a cumulative effect on an already distressing environment.
The home and the complex relation a service user can have with it is very much part of the
landscape of distress. The community that exists beyond the threshold of the home can be a
place to get away from the distress of the home, but it can also contribute in a significant way
to the landscape of distress.

A Distressing Community, A Distressing Environment

Communities tend to be difficult to define. Within Lambeth, an individual’s sense of
“community” can include a myriad of different places, spaces, and people. Yet, for some
service users, their sense of community is only as broad as the immediate area around them
and the health professionals with whom they interact on a regular basis. For the purposes of
assembling and exploring the landscape of distress, I need to take into account the relationship
between the built environment and people on the level of the community. In doing so, I use

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Ben Anderson’s idea of affective atmospheres (2009) to try and explore the relationship
between the built environment of the community and how it can have an immediate or passive
effect on a service user. In examining these relationships, I can explore how they can create a
sense of distress and also, in certain cases, provide a place within the community to escape the
landscape of distress. Below, a service user inadvertently explained the atmosphere of the area
outside of her flat.

So like at night it is a bit dodgy and because it’s such a mix of people here, a lot
of people clash. There’s a lot of people with mental health problems, there’s
refugees, there’s people who have lived here for 30 odd years and all of that,
and you know, there’s a lot of racism which is a thing that I find difficult
because I hear it all the time and I have to ignore it so as I can’t really get
involved and be like, “don’t be a racist”. Umm, and there was a fight umm, just
a few weeks ago now I think. And again, outside my kitchen window so I could
see it, I could hear it, and it was this rich white lawyer basically picking a fight
with someone because they had an accent.

The above quote is from Jane, a service user describing where she lived— a Victorian council
block forming part of a housing association not far from a busy street. There was an
atmosphere developed by this description of a quite distressing environment at night. I walked
down that same busy street on my way to interview Jane and I noticed that to get to her
council block, you had to pass through what looked like two poorly lit alleyways. I buzzed
into the courtyard through large cast iron gates that towered over me and I was aware of the
absence of CCTV cameras on my way through the courtyard. Jane told me that more lighting
in the alleyways had only been installed after a young woman was found dead in front of her
kitchen window. The atmosphere, as Anderson says (2009), enveloped and pressed on Jane; it
had a weight to it that created an experience of her environment as one of distress and fear.
Increasingly racist incidents challenged her moral being, making it both progressively more
distressing to witness the racist behaviour but also assembling an atmosphere that increasingly
weighed on her. This racist behaviour included the attack by a white lawyer on a man who
was delivering basic goods to a recently rehoused woman.

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The area directly around her flat had taken on an affective atmosphere that at times was one
of danger, fear, anxiety, or distress. Jane suffered from PTSD and some very complex trauma
which made these incidents that happened in front of her windows quite difficult to deal with.
Like the atmospheres of austerity that Hitchen invokes, through which “continual exposure
fatigues the body and can increase negative affects over time” (2016:117), the difficulty of
being in this flat took its toll. Between the fights, the murder of a young woman, and some of
the other residents being particularly difficult, intimidating, or flat out homophobic, Jane
would have regular relapses. The atmosphere of distress that existed in relation to the built
environment outside Jane’s doorstep was a consistent feature in her life. For other service
users, their relationship with other people helped to create that consistent atmosphere that
slowly wore on them.

Insignificant, day-to-day interactions like the ones that occur on public transport, can also
generate an atmosphere of distress and exclusion. I asked Diane about what London, and
especially South London, was like for her. She painted a picture of a place that carried a
constant potential for conflict.

No one’s nice to you, you know, people are too judgemental, it’s cold, it’s a
cold world, I mean a cold city, London. You could be on the tube and you just
made eye contact with somebody and they think that you either want to fight
them or you’re sexually attracted to them or something, you know? And it’s
not; you just looking, sometimes I’m not even looking I’m just day dreaming
and they’ll think something untoward and you’re thinking, “hang on, are you
serious? Seriously? You actually think…? Ok, I’m not going to get into
anything. I’m not going to get into a fight with you just because I looked at you
the wrong way”. Or you stand on somebody’s foot and that’s it, that’s another
fight, you know? I can’t be dealing with that on a regular basis, you have to be
very careful in London. You have to be very careful about everything, and it’s
over populated. I feel especially in -------, you just, ahhh [sigh], as I was walking
around, as I was coming here, this afternoon, I was feeling quite dizzy. There
was so many people around, I just thought “oh no please don’t let me die here,
you know please, I’ve got clean underwear on, but please don’t let me die
here”. I just didn’t want to die here because I felt like I was going to faint. It
was like a swarm of bees around you, you know what I mean?

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Diane related her experience of Lambeth as requiring constant vigilance and anxiety about
unwanted confrontation. This constant awareness was an affective atmosphere, so much so
that Diane complained that it felt like navigating a swarm of bees who all had the potential to
sting for unknown or trivial reasons. The feeling of being overwhelmed, of the presence of
people creating an affective atmosphere of distress in London, was quite common among
service users. Many dealt with panic and anxiety around large groups of people, which limited
their use of public transit and the areas they might visit. There were, however, islands of calm
where they could escape these feelings of exclusion and distress that were being driven by the
environment and social relationships.

One such place in Lambeth that provides temporary and positive reprieve from the landscape
of distress is a sort of clubhouse. This clubhouse is open to the public but is primarily for
people suffering from mental health issues. I spoke to a participant about this space and toured
it. It looked a bit like you would imagine a google campus to look—very open with lots of
computers, an atrium, and a café/restaurant area where food was cooked by members of the
clubhouse and served at discounted rates. Speaking about the clubhouse, Scott revealed an
affective atmosphere that allowed him to feel comfortable.

I said – after I had been there [the clubhouse] for about a month – I said going
there is better than all the medication I have tried, but yeah I really pick up on
vibes of people or rooms or even buildings and it is just really nice.

The clubhouse was a place where Scott felt accepted. Later, he told me that it was a place
where he felt at home, a place where he could act a “bit messed up or a bit eccentric” without
anybody taking notice. Even here the reach of the workfare state was felt, as one of the Key
Performance Indicators for the clubhouse was to increase “the number of members entering
and/or retaining paid employment”.38 The clubhouse positioned itself as a service that moved
people into productive and fulfilling lives. It did this by providing an opportunity to learn the
skills necessary to obtain employment. The skills taught were put together by staff and

38
This is a quote from a clubhouse document not cited to maintain confidentiality.

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clubhouse members and delivered through work on newsletters or classes taught on a
volunteer basis. For instance, Scott was able to take a course on assertiveness, as well as a
course on teaching. He then used these skills to run a Healthy Eating workshop at the
clubhouse. The model of providing courses that help to prepare the participant for work or
simulate paid work is very similar to the state-run conditional benefits programmes, although it
is important to point out that one can be opted out of, the other cannot. It is a familiar model
for many of the service users, but it still manages to provide a sense of belonging and
empowerment. Still, this is a place that some service users purposely avoid going to because of
the proximity with other service users who can be acutely unwell or because it is an unpleasant
reminder of how they might be in the future when they are unwell. Service users who turn
away from this space often struggle to find that sense of belonging or social solidarity that they
may have found in the past.

The strange thing is I do like Lambeth and the history, I love the fact that I was
probably – my sisters and I remember the Brixton riots back in the day and we
was actually there, which might seem a bit back in 1981. So yeah, those
memories make me have this fondness for South London, but it’s changed so
much I don’t like it at all. It’s so materialistic now, everyone is so shallow, you
talk to someone and all they want to talk about is clothes and hair and going to
this place and that place, nah, it’s boring. I think life should have substance
about it, you know, helping people… not all about me, me, me, me, me.

In the quote above Diane juxtaposed the social solidarity that she and her sisters felt during
the Brixton riots and compared this to the fractured sense of solidarity now, echoing views
that the most recent riots were more about consumption than solidarity. The kind of
outpouring of social solidarity around real issues in the community was something that she
lamented. It could be she was comparing the 2011 riots and riots in the 1980s, with the 2011
riots featuring youth raiding stores for sneakers, but it could also be related to long-standing
issues the area had around racism and institutional violence. To explore this, I need to
examine parts of the symbolic and social landscape that intersect with ethnicity, racism, and
the landscape of distress.

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Experiences of Racism and Prejudice and the Landscape of Distress

I mean it’s more cosmopolitan; it’s gone up market, especially Clapham and Brixton. There’s a
lot of bars and restaurants and I suppose it’s because a lot of white, English, middle-class people
moved into the area, and as you know that trend improves the environment, and they’ve
opened up a lot of bars and restaurants, they’ve a lot of estate agents around and stuff like that.
New, beautiful new houses around the place that have been built, get into all that but
unfortunately that’s the case, it works for them but not for us.

-Diane

The above quote is the response I received after I asked Diane, a black service user and long-
time resident (30+ years) of Lambeth, about the changes that had taken place in her
community. Granted, Lambeth as a community has changed rapidly over the last 20 years and
continues to change at a rapid pace with over 13% of the population moving in/out every year
(Lambeth Council, 2016). However, the last part of the quote above is worth exploring. “It
works for them but not for us” helps to underline the affective experience of the community,
which for Diane and many other service users was an experience of exclusion. Whether it be a
feeling of social isolation or exclusion, it pervaded the landscape of distress as an affective
atmosphere. The term “affective atmosphere” is ambiguous enough to sit “between presence
and absence, between subject and object/subject and between the definite and indefinite” but
one “that enables us to reflect on affective experience as occurring beyond, around, and
alongside the formation of subjectivity” (B. Anderson, 2009:77).

Take, for instance, the affective atmosphere that descended on London in the days and weeks
after the Brexit referendum. The Brexit campaign and the events after that campaign made it
strikingly clear that immigrants were not welcome. The decision led to the widespread and
open acceptance of an exclusionary politics already operating in Britain. As a result, there was
a dramatic increase in hate crimes and racism (Burnett, 2017). For immigrants and the Black
and Minority Ethnic (BME) community, Brexit and the reaction to it caused the atmosphere
of London, and Lambeth especially, to change overnight to one that made them feel
unwelcome and unwanted. Brexit is a major event that works to reshape Lambeth, as it has

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been and continues to be a major hub of immigration within London since the 1950s and 60s
(Howarth, 2002).

Lambeth and Brixton have become a symbol of black British community, but they have also
become a symbolic target of racism and racialised views of the outsider. To begin to take stock
of what is a disproportionate experience of the landscape of distress for the BME community,
it is necessary to first acknowledge that racism imbricates itself within the topography of the
landscape of distress and amplifies the landscape’s effects. The fact that they are often looked
upon with distrust or criminality in the very place where they grew up constructs a feeling of
exclusion (Howarth, 2002), a feeling that was only intensified by the Brexit campaign and
aftermath. This is not a new experience as Brixton gives rise in recent British culture to images
of racialised youth, anti-social behaviour, and gun and knife crime on the council estate
(Gilroy, 1991; Howarth, 2002). “Representations of Brixton shape the way that people from all
ethnic groups who live in the area are ‘looked on’ by others” (Howarth, 2002:247).

The intersection between the experience of exclusion, Brexit, and Lambeth was brought to
light again with the area being home to many of the “Windrush Generation”—a generation
whose children (now grown) have recently faced deportation from the UK because many
never “formally naturalised or applied for a British passport” (Gentleman, 2018:1). Without
documentation and because of stricter laws on immigration requiring proof of a right to work
in the UK, many unjustly face deportation or are deported. This incident only intensifies the
isolation of this community. It acts as another stubborn reminder to the black British
population in Lambeth that their existence is mediated by the policies of a government and
police force that have shown consistently that they are not wanted (Gilroy, 2008). This sort of
institutional racism is bound tightly to the history of South London and continues to affect its
population as austerity policies also have hit Black or Minority Ethnic people and disabled
people the hardest (Portes & Reed, 2017).

The intersection of these austerity policies, the creation of the deserving and undeserving
recipients of benefits, and the politics of exclusion came together most visibly in the response

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to the 2011 riots in South London. There was a long list of potential sources for these riots,
including austerity policies that produced some of the largest student protests in British
history; the shooting of Mark Duggan; and subsequent failures of the police to mediate the
situation. Despite all of these possibilities, and more, from which to choose, the rioting of 2011
was blamed on rampant consumerism and bad behaviour, with racist undertones (Jensen,
2013). In perhaps the most outrageous comment on the riots, historian David Starkey
referenced Enoch Powell’s rivers of blood speech, claiming that his “prophecy” was right, “but
it wasn’t intercommunal violence … what happened is that a substantial section of the chavs
that you [Owen Jones] wrote about have become black, the whites have become black”
(BBC1, 2011). This comment reinforces the politics of exclusion by pointing towards racist
ideas of how black people are a social contagion and represent an alien and non-British
culture. The internalisation of the commentary around these riots is evident in Diane’s
statement in the last section about how things have changed in Lambeth from the solidarity of
the riots in 1981 to the rampant consumerism that she detests. Indeed, most of the
commentary revolved around how these riots were “connected to an excessive and thus
problematic relationship to consumption and consumer desire” (Jensen, 2013:1.3). This appeal
to exclusionary politics that project an image of the working class BME community as a
dangerous underclass rife with moral failings connects directly with the dominant discourse
surrounding the moral failings of those on welfare; together they create an affective
atmosphere of distress that is increasingly difficult to escape.

The difficulty that some young black men and women had in distancing themselves from this
atmosphere of distress became evident in my interviews with them. Roland and Nermana
both had entrepreneurial dreams and wanted to pursue them by working steady, well-paying
jobs. The difficulty they faced in seeing these plans to fruition was due to a multitude of
factors, including living conditions, the stress of previous experiences of racism and
islamophobia, and the ability to stabilise themselves without help from family. For instance,
when I spoke to Roland about his thoughts on becoming unwell and aggressive (in the ward)
and what factors may have played into this, he told me about the prejudice he faced on the
job.

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 The anti-Islamic jokes they used to make, they used to – “you guys kiss the
floor” and I was so, you know, it was just – it was just mean. Me with – I was
19, 20 at the time and I just never held my head up or spoke out against it
because I wanted the job so bad; I didn’t want to get fired, I didn’t want to lose
it, you know? I didn’t want my wife to be like, “you’re not providing”. In the
end it was like, I couldn’t take it anymore. I just left because I made up excuses
like my mom’s – my mom’s going through a terrible time that’s why I’m leaving
but really, I was leaving because I just couldn’t take it anymore.

Roland tells me here about the great deal of stress and pressure he felt from the nearly non-
stop prejudice shown to him while he was working on a London skyscraper. Despite this, he
wanted to go back to work for the company, to dispel the myths that he saw the other
employees were getting from the TV and movies. At the same time, he knew that this would
take strength and character, and that when he left before, he had to take Job Seekers
Allowance (benefits) which led to his mental health crisis. This goes directly against the use of
rhetoric that vilifies those who may be sick or claiming benefits as lazy or undeserving or that
there are moral flaws amongst working class black people in Lambeth.

Nermana on the other hand had trouble gaining the support necessary to begin her pursuit of
an education and eventual entry into the business world. When I met her, she was sleeping on
the couch at her parents’ house. Nermana’s mother refused to talk to her and forced her to
sleep on the couch all because Nermana had decided to follow the Muslim faith. Though
Nermana suffered from delusions, she received no support from her parents as they
disapproved of her faith. I saw several other young black men and women who all felt the
pressure of racism which directly contributed to their relapses and stifled their ability to
succeed. Racism itself puts individuals at a high risk of developing psychosis (K. McKenzie,
2006) and other common mental disorders (Hatch et al., 2016).

For Roland and Nermana, the landscape of distress was ever present and amplified by their
own struggle with prejudice and feeling excluded from society. This amplification of the
landscape of distress only continues within the hospital, as I detailed elsewhere. There are, of
course service users, who have experienced the opposite effect. These service users have the
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resources necessary to quit the landscape of distress and the benefits of their access to
resources follows them through the mental health services. This offers the polar opposite of
the experience of many black service users, providing middle-class service users with an
experience that is a world apart, presenting a stark reminder of how recent austerity policies
have enacted a collective suffering in rhetoric only.

Silencing the Landscape of Distress

The landscape of distress was not experienced in the same way, if at all, by those who had the
resources necessary to silence it. The interviews and home visits I had with self-identified
middle-class service users did not feature housing disrepair, benefits, problems with money, or
much of an atmosphere of distress at all. There was, however, a sense of entitlement to
intensive and attentive treatment from the HTT or other services. Many staff mentioned that
they were careful about how they spoke, recorded notes, and approached middle-class service
users. When I asked why, staff often talked about these service users’ ability to effectively
navigate the bureaucracy, file complaints, and follow up with the right people. This brought
undue scrutiny on staff, whose electronic notes for every visit with those service users would
then be analysed as evidence of possible wrongdoing. The fear of this happening was enough
to create a constant awareness and attentiveness in staff, which may be why these service
users often received a longer, more intense service from the team. That being said, I cannot
comment on whether these two points were directly related or whether it was a case of
middle-class service users presenting with severe illness. If these middle-class service users
were, to a certain extent, immune from the influence of the landscape of distress, then they
may have presented much more acutely unwell because they had not had the daily wear and
tear from the environment, which might have generated help-seeking behaviour much earlier.

Middle-class service users were often unaware of just how different their treatment was from
other service users. Sally was unaware of how her considerable resources positioned her for
increased access to shorter term, more intensive treatment from the HTT. One of the
psychiatrists who was seeing this woman told me that, based on the obvious wealth of the
woman, she had made the decision to do some short and intensive psychoanalytic work. This

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is something the team would usually avoid as it could destabilise the service user. The
psychiatrist’s reasoning behind this occasion was due almost entirely to the ability of the
woman to quickly find, book, and, most importantly, afford private psychotherapy sessions.
Sally managed to book these further sessions with a local psychoanalyst just before the team
stopped seeing her. When I interviewed Sally, she questioned why she had received this
treatment.

I don’t know, I wonder how she came to decide to start doing that work
knowing that she wasn’t going to be able to continue with me. So I just
question that, is that, or is it just spontaneous that we ended up having that
conversation and then had to continue because it was an accident, or was it. I
don’t know what, her; I mean, I do wonder but I haven’t really been able to ask
her because it’s awkward … thank god I was able to see someone private.

Sally was unaware that her home and obvious income were taken into account in that decision
to provide psychoanalytic sessions. The team assumed that she would be able to afford private
sessions and the team psychiatrist saw this as an opportunity. Sally was able to not only avoid
many of the difficulties of a landscape of distress by having stable housing, income, etc., but
she was also able to receive a better level of treatment from the team because of her resources.

Some service users are so far from being touched by the landscape of distress that they
actually have not even thought of common supports. Take, for instance, Elizabeth, a young
woman who owns and runs her own business, has two degrees, and a very supportive family. I
asked her if she had ever used the benefits system in the wake of her repeated relapses and
suicide attempts. She shook her head and said, “Sometimes I should have but I think because
I’ve always sort of … no I haven’t, and I should have done, especially in those days in my 20s
when I wasn’t working”. Here Elizabeth was actually surprised by what I said, having not
even considered benefits before. To have not even considered benefits while living in London,
not working, and dealing with multiple relapses, revealed just how privileged she was.
Interestingly, she lamented the fact that she had entered into the creative industry and told
me how, if she could go back and do it again, she would choose something that was more
stable.

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 I would have like, tried to make my life. I wouldn’t have gone into a bloody
creative industry, do you know what I mean? I would have tried to – it’s
hindsight – tried to make the rest of my life as stable as it could be so there
wasn’t other instabilities.

While Elizabeth might not have been as embedded in the landscape of distress as Roland or
Nermana, she still had an aspect of her life that wore on her, that she experienced as
distressing. There are multiple ways of experiencing the landscape of distress, which, might
not necessarily produce an awareness of other aspects of the landscape. Sally existed apart
from the landscape almost entirely and did not seem to be fully aware of the way her access to
resources reshaped her landscape. Whereas Elizabeth, who had not even thought of benefits
despite being in a situation where, without access to significant resources, she could have
ended up homeless, still experienced a facet of the landscape of distress. She identified
London as a stressful place to work, and her job within a creative industry as very competitive
and unstable. This instability in work is an aspect of the landscape of distress that does find its
way across the boundaries of wealth and privilege (though it does so unequally).

Precarious Employment and Distress in Work

The landscape of distress that exists in Lambeth is often enhanced by conditions of precarious
employment, something which now affects all levels of society. The Office for National
Statistics recently reported that six percent of UK employment contracts (1.8 million) are
zero-hours contracts which do not provide a guaranteed number of hours (2018). Not all of
these contracts are necessarily bad; however the practice of shifting risk from the company to
the individual, and creating economic and job instability within the lives of their employees, is
creating what some argue (McKee et al., 2017; Standing, 2014) is a new precarious class.
Although my research cannot confirm the existence of a new class, the very fact that it is
being brought up by others is evidence of how much relations between employees and
employers have changed. The rise of contract and temporary work has brought increased
precarity to the lives of many, especially those already on the margins of society and claiming
benefits. In this section, I will explore precarity in work to add another dimension to the

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landscape of distress, beginning with workfare and moving towards those in gainful (yet
temporary) work.

David Harvey provides a good initial starting point for looking at precarity and employment
by making the claim that “sickness is defined under capitalism broadly as [the] inability to
work” (2000:106). He goes on to talk about the impact that labour and the production of
surplus value has on the body, that it and other practices of modern capitalism can grind down
the body and mind. Research overwhelmingly backs up the negative health effects of
economic and job insecurity for those in flexible work (Godin et al., 2005; Jenkins et al., 2008;
Rohde et al., 2016; Thomas et al., 2005; Watson & Osberg, 2017). Short-term and zero-hours
contracts have also been shown to damage mental and physical health (Aronsson et al., 2002;
Benavides et al., 2000; Henderson, 2019; Sanwald & Theurl, 2014). The longer people work
these contracts, the more likely they are to suffer ill health effects (Bender & Theodossiou,
2017).

With the new precarity in the labour market, the relationship between economic insecurity,
job insecurity, and mental health revealed itself on a daily basis with many service users
presenting in acute distress that they attributed to their working conditions. For many, efforts
were made to return to work before they were ready to avoid going further into debt, being
evicted, or worse. Some were on zero-hours contracts while others were on relatively more
stable one- or two-year contracts. Christina, a young teacher who had recently moved into
the area to be closer to the school at which she taught, told me about the difficulties that she
faced bouncing from contract to contract.

Previously I’d taught a year at a school and then I’d be somewhere else because
I was only getting temporary contracts, so that didn’t really help with my
mental health because I was having to start over all the time; by the time I was
settled, come January, I’d have to look for a new job for September and it was
very difficult to manage… You know, the nature of temporary work is, you
know, I got a reputation for being a great teacher that could go in, take on all
the responsibilities, get, secure great results for year elevens in a year and, you
know, go on my way again. So, I was really, kind of an enemy of my own

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 success in my opinion because I would – I had this reputation, that’s why I
would secure a job, and then I would have to fulfill it.

Christina in the above quote directly attributed her time working one-year contracts as bad for
her mental health, partly due to the insecurity of having to begin looking for another job
before her job had even finished and partly because being good at her job intensified the
expected return for the employer. Numerous individuals seen by the HTT were working
contracts like Christina and, despite some of these contracts paying well, they were still seen
as major sources of stress in their lives. The difficulty for Christina was being honest with her
manager about the difficulties she was having with her mental health. She would talk to some
of her colleagues about it but for the most part she took sick leave for physical reasons rather
than explain her mental health difficulties. She did so out of fear of the potential repercussions
and the associated stigma around mental health difficulties.

Some employers were more aware of the difficulties of returning to work after a mental health
issue. For example, John worked in a fast-paced environment but had a manager who knew
about his difficulties. The manager was able to organise a graded return to work which helped
to support John and not put him at risk of relapse. Many service users had repeated and
badgering phone calls from their employers asking for specific return dates and constant
updates. John’s employer trusted him to know when he would be ready for work and allowed
him to guide the process at a pace that matched what John could handle. He is unfortunately
the exception to the rule, and was the only individual I talked to who listed his work as part of
his support system.

The increased precarity in employment does not work to the benefit of the employee and for
many it is moving them closer and closer to claiming benefits and possibly losing their homes if
they should fall ill, especially with housing costs in London. For those who manage to stay
employed, many of their employers are not capable of understanding the complexities of
recovery from mental health issues—meaning they often fail to provide an employee with the
conditions necessary to make a transition back to work a successful one. The insecurity that is

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increasingly built into the experience of holding steady employment contributes to the
construction of a landscape of distress.

Constructing Landscapes of Distress

The concept of a landscape of distress is a complex assemblage of different aspects of the built,
social, and symbolic environment that give rise to distress. This complexity makes it
worthwhile to provide a recap of the pieces that come together to construct such a landscape
of distress. The concept of a landscape of distress is based on Gesler’s (1992) therapeutic
landscape, which views particular environments as contributing to a “healing sense of place”
(Bell et al., 2018). A landscape of distress contributes to an interface between individual and
environment that is mediated by anxiety and engenders distress. The landscape of distress is,
as David Conradson understands therapeutic landscapes to be, “a relational outcome, as
something that emerges through a complex set of transactions between a person and their
broader socio-environmental setting” (2005:338). This setting includes the way that the
government has shaped discourse around benefits claimants, representing them as symbols of
economic, social, and individual failure while at the same time reshaping the system,
increasing conditionality, and creating a system that produces distress and anxiety. The
conditionality in the system and discourse around the undeserving poor can and does reshape
service users’ views on their own value to society, leading them to wrongly believe that they
are a burden on society, causing them to question if “there is a duty to die” (Barr et al., 2015;
Ryan, 2017).

The homes that service users reside in often reflect the diminishing of their own personal value
as they are forced to fight, not just for basic repairs but for the right to remain a resident in
their community. The result of austerity policies and their impact on local councils has created
a situation where council estate regeneration is argued to be in the best interests of residents
who are then decanted to another area, never to return. This can create the experience of
being moved from one mouldy and poorly repaired flat to another, reinforcing the notion that
society no longer has a place for them. These poor housing conditions contribute to illness,
increasing the impact of symptoms and, in some cases, developing a spatialisation of the

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illness. There is no quick treatment to these conditions. The housing stock is far too low to
permit easy movement; instead service users are forced to stay in their homes.

The neighbourhoods in which they live can also become increasingly distressing places. The
rise of an exclusionary politics and Lambeth’s contradictory stance as a place of settlement
bring tensions to the surface, contributing to an atmosphere of anxiety, distress, and exclusion.
The physical design of public spaces on estates, the neglect of councils to properly light some
spaces, or to light and fence other spaces, so much so that it resembles a cage/prison,
demarcate these spaces as dangerous (L. McKenzie, 2015). There are refuges available within
the community from the currents of the landscape of distress. Some of these refuges are
constructed within the dominant discourse that sees the only worthwhile service user as one
who has found a way to be productive within the capitalist system. This is the same system
that is providing job—low-paying jobs that are so insecure as to actually harm the mental
health of employees.

The experience of a landscape of distress is, of course, a subjective one. Just as someone who
suffers from PTSD will read certain situations or configurations of the built environment as
hostile, anxiety-inducing, and triggering places and spaces, so too will some individuals
experience a landscape of distress. The difficulty is that some people experience the landscape
of distress disproportionately, with layers of distressing experience that are far more intense
than other people. Sara MacKian draws attention to the construction of therapeutic
landscapes as an unequal and political process that both empowers and marginalises (2008). In
this case, it is clear that some people are empowered. White, middle-class service users can
quite easily stand up to stigma, avoiding the worst of the landscape of distress, whereas poor
black service users face a distinct disadvantage as they are treated, knowingly or unknowingly,
in racist ways that diminish their ability to deal with the landscape of distress and receive a fair
service. Similarly, Conradson draws attention to the fact that many therapeutic landscapes are
out of reach of all but the dominant groups within society (Conradson, 2013). You cannot
afford to take advantage of the beautiful countryside and revitalising experience of the
seashore if you cannot afford to get to these therapeutic landscapes. In this case, landscapes of

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distress can be avoided with the requisite resources, but not everyone can afford to avoid
them.

What of the HTT? Are they to be found traversing across these landscapes of distress? The
HTT can provide an exceptional counterbalance and treatment for the landscape of distress.
This landscape engenders a feeling of not just distress but one of being out of place, of not
being wanted, of there being no place for them. The most radical thing the HTT can do is to
spend time with the service user, to make an effort to renegotiate their relationship with the
space and show them that there is a place for them. The affective atmosphere of distress can
be disrupted by the team through the process of home visits and other activities that help to
renegotiate the service user’s interface with their environment—spending time being there,
doing things that recognise the worth of the service user and help them to recognise that
worth within themselves.

A team member recalled taking a service user out to a movie on Christmas. Their reasoning?
Because who else would do it? Despite a lack of time to do things like this, the team retains a
powerful treatment for the landscape of distress in the ability to shift a space from a landscape
of distress to an atmosphere of care, through a therapeutic encounter. Conradson (2003) draws
on Carl Rogers’ person centred therapy to describe such a therapeutic encounter. There are
three aspects to such an encounter, that are as follows: being genuinely present and authentic;
being unconditionally positive, accepting, and caring; and finally displaying an empathetic
warmth, “sensing the client’s private world as if were your own” (Ibid:512). Those are the
qualities that were present within HTT interactions that were able to pull the participant out
of a landscape of distress for a time and into a space constructed through the caring relation
and therapeutic encounter. Those are the things that are both most needed and most at threat
due to the changes brought about through the “age of austerity”.

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Chapter 10: Conclusion

This ethnography began with an exploration of the history of home treatment team
development. I used insights gleaned from this history to inform a detailed analysis of their
current practice and place within the mental health system. I then followed the emergence of
home treatment out of austere conditions to their use by an NHS Foundation Trust to
manage austere conditions. Their utilisation in this way evolved throughout my time with the
team through the consultation and other events that shifted practice and sped up their work at
the behest of the Trust. This, in turn, influenced the experience of the team’s service users in
ways I explored with the help of concepts such as timescapes and time-space compression.
This exploration ultimately led me to construct a concept to map the landscape of distress that
was being described to me by participants. Such a landscape exists for each individual and
contributes to the worsening, extension, or relapse of their mental health difficulties. The
landscape itself is not something entirely new, emerging out of changes made to the benefits
system and other support systems which have been accelerated by recent programmes of
austerity.

These elements in my research will be brought together in this chapter to provide a more
general discussion of the main themes that have emerged throughout my work. I will also look
forward towards what might be expected and what ought to be investigated in regards to
HTTs. Concretely, I will begin by looking at the political economy of care that emerges from
the Trust’s efforts at service redesign. I will then bring together the concepts of speed and
time throughout the system, drawing on the political economy of care. From here, I will move
to outline what the consequences are of the political economy of care, and speed and time. I
will then bring together the concept of a landscape of distress and place it within research
around the social, political, and economic determinants of health. I will use the concept of
cruel optimism as a way of bringing home the importance of what home treatment does and
what is being done to home treatment and its service users. Finally, I will point out some
broad policy suggestions based on my work in this dissertation.

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A Political Economy of Care
There is a particular political economy of care that can be pieced together from the history of
the HTT, current practices and changes, documents, and the restructuring of the service—
most of which is directed towards delivering the most cost-effective service possible. Home
treatment emerged from an austere environment as a way to limit the expenditure of funds
while still providing a level of care to service users. It developed alongside an economic logic
that saw it as a way of reducing the cost of care by limiting the use of inpatient beds. After its
implementation, bed levels began to plummet in the UK, and the HTT was used to manage
capacity. The advent of further cuts to mental health services and the flexible nature of home
treatment practice paired with the marginal evidence that suggested a reduction in bed use
made HTTs the ideal candidates around which to build cost reduction strategies. In chapter 7,
I explored the development of a political economy of care within the Trust and tracked its
influence through a related service redesign. While examining the service redesign process
and the related consultation, I showed that, despite paying lip service to the quality of care
and patient centred care, the Trust was more concerned with finding cost efficiencies and
using the HTT to manage bed stock and minimise out-of-area placements.

This political economy of care is not as simple as less bed use equals more efficient service. It
requires redesigning pathways through teams and also redefining what the word “crisis” in
“crisis care” means. For instance, the Trust redesigned the experience of crisis care by placing
the Triage ward in between the HTT and the other wards. This redefined those other wards
as “long-stay” wards. The placement of this ward changed the definition of a crisis, essentially
creating a new practice of short-term stays on an acute ward for a crisis. The Trust then
started a process of changing the definition of a crisis again by beginning to force home
treatment to take on more and more acute service users. The overall acuity of service users
rose across the system, changing the threshold for a hospital stay. This artificially created
capacity within the system as the acuity increased across the system, resulting in the HTT
being relied on to keep increasingly unwell service users in their homes. The team does not
have to agree with this—they can even push against these referrals—but if most or all of the

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discharges they receive are at a certain level of acuity, then eventually that becomes the new
normal. If this sounds familiar, it is, because the Trust makes the same claim but in the
inverse—that any level of beds will be used to capacity because the threshold to admit will go
down as the supply of beds goes up. Therefore, this political economy of care is, in many
ways, a balancing act between too many beds and too few beds, and it hinges on a definition
of what a crisis is. The difficulty with this is that we often look at the beds and thresholds but
not at the time spent in those beds.

To eke out more capacity within the system, the Trust is actively rearranging its services to
not only produce friction between services but also to shorten the length of time spent in the
services. The creation and operation of Triage wards has produced an effective gatekeeping
system, placing another layer in the system between the service user and a long-term
psychiatric stay. This is only possible when service users have an intermediate service that can
closely monitor them in their homes to reduce the risk. The more difficult the Trust makes it
to be admitted to the ward, the more people circulate through home treatment. Pressure is
then applied to home treatment to discharge people more quickly to create more capacity,
essentially moving the HTT to a one-in-one-out policy. All of which allows the Trust to
artificially manipulate the threshold, acuity level, and the time spent in hospital. The time a
service user occupies in a bed or spends with a service is then tightly monitored and controlled
to the extent it can be. Each service in the mental health system is broken up into weeks,
days, and hours, and tightly managed to specific performance indicators around speed and
efficiency. This creates acceleration by virtue of closing down the time horizon and focusing
on more minute fractions of time: from bed days to fractions of bed days.

The time-space compression not only accelerates the flow of patients through the system, but
paradoxically also produces gridlock. A service whose time horizon has reduced to the extent
that it is controlling flow through the system by fractions of days cannot look far enough into
the future of both services and service users’ lives to avoid issues that produce a higher rate of
relapse among service users. Watching as service users return again and again to the team with
the same issues unresolved and similar solutions sought drives the imagination of team

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members towards creating services that specifically focus on stubborn issues that have not
been addressed. Such an imagined service might have a longer time horizon, giving them the
ability to not only formulate long-term issues like housing (e.g., mould, damp), social care
(e.g., personal support,
medication support), and
chronic physical health
issues (e.g., diabetes,
obesity, heart conditions)
but to also address those
issues from start to finish
without handing off the
service user to another Figure 5

service. The exasperating part is that this is the very definition of what services like CMHTs
used to be able to do.

The actual design of this system appears to those who work in it to be directed not towards
finding the most stable caring arrangement, but finding the one that costs the least. This
results in a trial-and-error process to find the lowest cost. With the inability to address
complex issues in service users’ lives, the political economy of care twists the mental health
system into the figure-eight shape illustrated above. I purposely illustrated it as a closed loop
without recovery because so many of the issues that create relapses are not able to be dealt
with in the time it takes them to move through this loop. The mental health system within the
Trust is a zero-sum system—investment in one service draws from another, creating more
issues. As home treatment receives more resources including an additional pool car and more
staffing, this money comes from another part of the Trust, draining resources from services
that might be able to address complex issues. The design of the system is closing the loop and
it has an impact on the practice of the HTT.

The Political Economy of Care and Home Treatment

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 So much of it [home treatment] is, umm, systems lead, isn’t it? It’s process driven work, isn’t
it? I had this conversation when I first joined with a person who was actually on their way out
of the team at that time. To be a carer these days doesn’t necessarily mean that you have to be
particularly caring as an individual; which is quite profound, but it’s - that’s, I think, what
systems can reduce you to if you’re not careful. Well, when we take this person on there’s a gold
standard of paperwork that needs to be complete; there’s a gold standard of verbal handover
that needs to be performed; there’s a medical review that needs to be facilitated; there is a joint
review that needs to be scheduled; there’s, ah - it’s all very much “have you done that, that,
that, and that”. Where is the - where is the warmer stuff in all of that? Again, it’s the stuff
that we talked about that you can’t standardise. Is it - is it actually at risk of being ironed out
by the fact that there’s so much turnover that in the end, all that you can focus on is process
because there isn’t time for much else - both between ourselves and the patient, and between
staff and other staff? You know that’s a real black hole I think.

-Team Member

The above quote provides a recap of what I have argued elsewhere in this dissertation. A
political economy of care can and does clash with the ethos of the HTT, with important
negative consequences. The team member here draws our attention to a dichotomy between
caring and process, a dichotomy that frequently appears in my examination of the team’s
practice. So, how does one serve the needs of the Trust and the needs of the service user at
the same time? As I showed earlier, the consultant must strike a balance between caring work
and keeping the doors open and service users moving through the HTT. In doing so, he has
the team concentrate on process and moving service users along so that there is time available
to do more intensive caring work for service users who really need it. Difficult choices have to
be made about who receives extra care and who does not. This is while the more granular
aspects of care are pushed aside in order to fulfill a gold standard of paperwork and the
process-based tasks that are necessary to move service users on.

As pressure mounts on the HTT to open up space on the wards and the team reaches the
upper limits of their capacity, home visits become shorter and the amount of time to make
decisions decreases. Little time is left to provide adequate supervision and develop self-
reflexive practices, which leads to tension and frustration between team members, making the
team more difficult to manage. The trouble with concentrating on process is that everything
else has to fall in line behind the need for efficient movement through the system. Emotional

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labour becomes increasingly difficult to achieve when time is short. Therapeutic encounters
become problematic without the time necessary to be truly present within the encounter.
Medication regimes are chosen because they are fast-acting, regardless of their side effect
profiles. The quality of the service suffers when time is no longer available for many aspects of
caring work that sets the HTT apart from other services.

In the consultation documents, a team member quoted the Francis report, calling attention to
the risk that the changes being made to the service would produce “a culture focused on doing
the system’s business—not that of the patients”. The balance between doing the system’s
business and doing that of the service users was left up to the teams themselves. The Trust’s
political economy of care was primarily concerned with running an efficient and speedy
service which would in turn provide a cost savings and net benefit for the Trust. The Trust
valued process-driven work over the more granular aspects of caring because it could be
measured and performance-managed. The quality of the service, on the other hand, was
ultimately up to the consultant and team members which created a system that operated
through conflict with itself. The role of mental health staff was to push back against the
system’s business, to steal time for caring, to find ways to promote therapeutic encounters as
much as they could. It may be that this push and pull between process and caring is how a
balance was struck and maintained. Such a system that operates best when its staff speak truth
to power ultimately cannot be maintained forever, especially in this increasingly austere
system.

The future of the Trust’s political economy of care is more control over finer aspects of
services by managing the performance of services based on data sets collected from the
electronic note system. The difficulty with this is the reliance on data places more demand on
good quality, detailed notes which take time to produce and would ultimately take time away
from therapeutic encounters. If the Trust were to increase the quality of data collection and
account for the time to collect it—there were proposals to do this, which included having one
team member drive while the other wrote notes on a laptop—they would still have to find a
way to measure the right things. How would one go about measuring care as opposed to

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throughput? There are examples of measurement that exist outside the confines of the
therapeutic encounter—outside the bounds of the home visit—but are not based on
throughput (Goldberg et al., 2016), but these are time intensive. Using large data sets to try
and find ways to identify service users who might pose difficulties on the ward, need longer
stays, or might be more amenable to home treatment rather than hospital visits is more or less
what the Trust is aiming towards. Data and the algorithms that act on data, which could aid in
reducing costs, accelerating services, and guiding treatments, might also discriminate against
particular groups of service users. For instance, we know that algorithms used in hiring
(Dastin, 2018), courtroom sentencing (Angwin et al., 2016), and determining mortgage
eligibility (R. Bartlett et al., 2018), among others, have all ended up discriminating against
ethnic minority communities and women. With the difficulty already seen within the NHS of
using “personality traits” as a shorthand for difficult patients, basing decisions off data might
lead to negative outcomes for those who are already disproportionately receiving an unfair
service. The current evidence that is drawn to support the political economy of care is often
weak, circumstantial, or created for the purpose of proving something that works—which
mirrors economic austerity policy in more ways than one might expect.

The political economy of care seeks to expand the capacity of the mental health system while
cutting funding, increasing efficiency, and substantively altering the interface between system
and citizen. Its goal is to expand service through contraction. This is exactly what austerity
policies are meant to deliver: economic growth through contraction. The difficulty is that the
“growth” that the political economy of care creates is a momentary artefact of speed; one that
is ultimately unsustainable. Just because more people are moving through the system does not
mean that the system is more efficient. Indeed, it may be that moving more people through
the system just means moving five out of the ten people through the system a second time
while the other five move through the first time. While the cost is reduced by moving a
service user through the system faster, the overall lifetime cost goes up as the person relapses
and moves through the system again (and again [and again]). The cost of such a system would
quickly outstrip the savings, but, in the short term it will certainly appear as though it has
succeeded. Is there evidence for this claim? There are some figures that may lend some

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support to this, for instance, the rapid increase in involuntary hospital admissions since 2008
which now outnumber voluntary admissions (Allison et al., 2017; Keown et al., 2018). For the
most part, however, it is difficult to know if the rate of readmission to mental health services
has increased since 2008. Nevertheless, there is evidence, for South London in particular, that
increased readmission is associated with shorter stays in hospital (Tulloch et al., 2015).

The link between readmission and shorter hospital stays is concerning, especially given the
way that this political economy of care focuses on measurement to attain its goals. The NHS
mental health system has entered a new phase of development with pay-by-results (PbR)
tariffs. Trusts are paid a flat fee per service user, either per episode or per year of care (Jacobs
& Barrenho, 2011; Moran et al., 2017; Yeomans, 2018). This being the case, the emphasis on
creating a more efficient service would be on a shorter length of stay to reduce costs, thereby
earning more from each service user. Following this logic and because there are no guidelines
on length of stay, “decisions regarding duration of hospitalisation could be driven by economic
rather than clinical considerations” (Capdevielle & Ritchie, 2018; Moran et al., 2017:198). This
is concerning, especially for black service users as evidence points to them having longer
lengths of stay and, thus, they would be considered less profitable for mental health trusts.
The PbR tariffs could have unintended and institutionally racist effects; they also negate the
value of the warm, caring elements of the mental health system that are generally more time
intensive. As I finished my study, the Trust, in an effort to reduce readmission rates, had
made home treatment mandatory aftercare although there was no evidence that this would be
beneficial.

Temporal Landscape of Home Treatment

This political economy of care casts a temporal effect by speeding up the rate at which service
users move through the system. This has a ripple effect throughout the system, (re)composing
the rhythms of institutional and personal timescapes. From the difficulty of allocating visits in
home treatment when the service is at capacity to the orchestration of multiple services to deal
with complex issues in service users’ lives, the acceleration in the system disrupts timescapes,
reduces timescales, and creates new rhythms to adjust to. With the increase of speed and

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patient flow, services also have to deal with the inverse of speed. As I have argued earlier,
Paul Virilio(1986; 1997) coined the dromological law, which predicts that the rate of
acceleration increases in lockstep with the rate of gridlock , the idea being that with more
speed comes an increased risk of events where all momentum halts. Hassan (2009) gives the
example of the speed at which the market was able to accrue short-term profits with dodgy
loans which ultimately led to the 2008 financial crisis. Within the mental health system,
increasing the acceleration of service users through the system creates gridlock by quickly
overstepping capacity in various services. The pathways into these services face a similar
acceleration and risk of gridlock; for instance, Mental Health Act assessments are delicate
orchestrations of a number of resources. When these feats of orchestration are sped up due to
patient flow and short windows of availability for resources (police, ambulance, private
psychiatrist), the chances of them succeeding (without violent confrontation) are lowered
significantly. Other examples that require orchestration of multiple services towards
addressing complex issues in a service user’s life are difficult to say the least. Organising a joint
meeting with all of those services, coordinating action, and maintaining close contact can be
extremely difficult, especially under pressure. These efforts can easily break down, preventing
the necessary changes in a service user’s life and leading to repetitive relapses. The rhythm of
the mental health services can only be accelerated so much before it begins to fall out of time.
This is something that also needs to be looked at more carefully in terms of its impact on
individuals.

The rhythm of home treatment is found within the length and number of visits per day across
a number of days or weeks. The rhythm is used in treatment, both as a source of containment,
with a visit in the morning and one again in the evening giving structure to the day; and also,
as a litmus test of sorts, to see how well the individual is doing: can they cope with a visit
every other day? The service user’s own rhythms are not altogether ignored, although
sometimes they lack attention. Most mental health services offer very limited support outside
of working hours, which tends to punish those who must work to survive. It sets up a situation
where those who tend to be at the bottom of the wage scale are incentivised to drop out of
work during a crisis to access more intense services. For those who cannot access benefits,

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they are left trying to work through a crisis while receiving help. Sick leave can also cover
time spent with the HTT but not with the CMHT, so the option becomes take a day off
work every other week or miss the visit. What about other rhythms like waiting?

I mentioned a service user who, I argued, was ultimately destabilised by her experience of not
being at the very least put on a waiting list for therapy. One neglected rhythm of mental
health services is the rhythm of compressing distressing experiences and then decompressing
those experiences at the right (in a therapeutic space) or wrong moment. A waiting list, I
argued, would have been some benefit, perhaps providing some containment or rather
compression with the knowledge of a later decompression. The difficulty is when the
compression stretches too long—it destabilises the service user. It can also act to fragment the
narrative compression in such a way where distressing aspects of the experience are prioritised
for decompression. This could lead to longer and longer periods of decompression. This may
be a misunderstanding or a fragmented understanding of therapeutic processes, but it stands to
reason that the longer one waits, the more distress one experiences, and the longer and deeper
need to process that distress. Compression and decompression work with gathering narratives
from the point of view of HTT staff.

As the team operates at quicker speeds and the actual time spent on home visits compresses,
so too does the information collected during these visits. The service user must use these visits
to convey a specific narrative that is compressed for time and, if the team member who sees
them is unable to read the notes before the visit, it means reformulating a compressed account
of their illness. Time is at a premium for the HTT. However, in some instances team members
are required to slow the process down, especially when service users and their families are
overwhelmed or when it takes time for someone to form their thoughts. Slowing down helps
to remind the team member that moments of silence within the interaction with the service
user are not wasted. They are necessary and can be used to draw answers out of the service
user, or just to give a sense of being with them; not all space/time can be filled nor should it
be. I sat at a kitchen table with a young man suffering from a difficult to treat psychosis. The
mother had told the nurse that he enjoyed talking to me. When I asked him questions, I used

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the basic interview techniques that I had been taught in qualitative research: give the person
time to formulate a response and answer the question. Leaving space in the form of silence
after a question encourages people to speak. I was able to draw out information that impressed
the nurse with me. On our way back to the team base, the nurse commented that I was very
good at asking questions and getting answers but most of all, I was so patient. Patience is
something that is very difficult to achieve when you are in a rush. The warmth within care is
created in the way it is delivered; it takes skill, effort, and time to converse in a therapeutic
way without falling victim to the paradox of repetitively asking about risk. The difficulty
when the team is short on time is less effort goes into interpreting service users’ difficulties and
more reliance is put on previous experiences. It becomes easier to see personality traits,
complex trauma, or troublesome behaviour as personality disorder. The way that service users
are talked to, the words that are used, and the intention that the team member has, are all
crucial aspects that can make or break a visit or an intervention. The way that service user
narratives are then subsequently written up is also important.

Electronic note systems facilitate the bulk collection of information from every interaction a
service user has with a service. The information collected is extensive and is notoriously
unreliable. It also reflects a cascade of compression that begins with service users
communicating a compressed narrative, which is further compressed as it is written into the
electronic record, and then again in weekly reviews. The reliance on electronic notes means
mistakes are harder to catch and there is less time to examine them critically. For instance, an
entry could describe an entirely different person and since it is the most recent and detailed, it
might be considered the truth. Attempts to standardise the entry of notes would only answer
the questions that are part of a standardised set, potentially leaving behind important
elements. It takes time to sift through the notes, as one set cannot provide a well-rounded
knowledge of the individual.

The team tried to facilitate greater access to notes in the field by issuing iPads with mobile
data service to all staff. However, the iPads were not reliable, so instead of reading the notes
in the morning and taking up time, team members spent time waiting in the car for the notes

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to load, if they did at all. There were areas where technology would have significantly
reduced time and stress in the team. The allocation of home visits can sometimes take an hour
to complete and involves increasing levels of stress and sometimes multiple staff to complete.
A simple algorithm would reduce time spent here to nil, creating a net gain of time for reading
notes and preparing for visits. This, however, is not an area that the Trust cares to address
because it would take an ethnography to identify it as an issue. Sometimes it is the simplest
elements of medicine that can be turned to.

Victoria Sweet, a doctor and author of God’s Hotel, speaks of time in terms of physical health
and healing, stating that “sometimes, time is the most important ingredient in a patient’s
treatment” (2013:110). Sweet describes in her book a struggle between a hospital that was a
relic from another era, that was slowly converted into a modern, fiscally prudent institution.
The difficulty with this was that the old approach to medicine present in the hospital made the
application of a “tincture of time” possible. Sweet (2013) argued for slowing down medicine to
heal in a way that was often successful where other quicker methods might have or did fail.
HTT members often recalled the old times (ten plus years ago) when they, like Sweet (2013),
could make “efficient use of their inefficiency” by taking service users to do much more
intensive things or take them to a movie on Christmas. The difficulty now is that a new
political economy of care is using speed as a means to create capacity, all but eliminating the
careful and judicial application of time.

In general, time needs to be taken more seriously, by the Trust, the team, and as a component
or even focus of social science studies in mental health. There are no guidelines for length-of-
stay when it comes to time spent on the ward, time spent with home treatment, or even time
spent in a home visit. In some respects, this should remain the case, but in others, it is clearly
not therapeutic to rush people along for the sake of ticking a box or saving a fraction of a bed
day. Mental health treatment lives and breathes; it is not an exact science nor is it an art to be
done to someone. What does it mean to say it breathes? There is positive time, in that there is
time that is taken up by talking or visiting, the actions of home treatment. There is also
negative time: time spent outside of the home visit, time spent being, witnessing, listening,

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waiting. This negative time is just as important and can have beneficial effects that can equal
some interventions: the decompression I was able to provide one family just by listening and
being present, the act of being with someone, of building a stronger rapport. Letting treatment
breathe is a powerful and timely thing that threatens to be lost with the acceleration in patient
flow.

The social and more intensive interventions that home treatment deploy are also in threat of
being lost. Can they sustain these interventions? Can they work to create time for these
interventions or will their efforts only accelerate things to a point at which it will be
unthinkable to be so spendthrift with time. These are important questions to ask that can, of
course, only be answered in time. Ultimately, the team will enter into its own negative and
positive space, where keeping the flow steady will form negative space and those fleeting
movements where they can invest time and energy into doing incredible work in the
community will consist of the positive time. Ironically, this process will entail its own waiting
and perhaps waiting list. Unfortunately, with the lack of time to do these things, the list of
who receives such interventions will shrink, potentially causing historically underserviced
groups to suffer.

At the Margins
Who does the political economy of care effect the most? To answer this question, it is useful
to recall what one team member said:

I think if you’re not white, I think especially if you’re black and non-British and
don’t have a good command of the English language and so are less able to
advocate for yourself; I think you are less likely to get a good service from this
team. I think you have a continuum and at one end you would have a
demographic group who are white and middle-class regardless of their gender
and at the other end you would have the black and non-British client group and
I think that your success in getting a good service from this team will largely be
determined by where you are on that continuum.

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This continuum present within mental health services is not going away. In actual fact, it has
existed for more than 20 years, to an extent that recent efforts were made to address past
failings within the Royal College of Psychiatrists and to address the ground level problems in
Lambeth (Browne, 1997; Davie et al., 2014; Fernando, 2017; Keating et al., 2002; Royal
College of Psychiartists, 2018). The Lambeth Black Health and Wellbeing Commission
published a report in 2014 on black mental health which supported the view espoused in this
dissertation, that services should be taking a life-course approach as well as significant steps are
needed to attain care for BME communities that is equitable and equal to care given to others
(Davie et al., 2014). There were still some gaps present within their report, one of which has to
do with pressure on services and the use of physical and chemical restraint. This dissertation
provides a link between the use of physical and chemical restraints, which they correctly
identified as being overused, to pressures in the system that produce this overuse (Davie et al.,
2014:47). Recent evidence supports the negative influence of pressure, driven by austerity, on
the quality of care provided by health care practitioners (Owens et al., 2019). The answer to
these issues raised in the Lambeth report is more training for staff but this fails to grasp that
one of the issues at play is the lack of time and low levels of staffing that keep de-escalation
strategies and other training from being effectively used.

SLaM, the local mental health trust, presented its case, a case for the political economy of
care, to the commission. They told the commission that “if the number of inpatient beds is
reduced then there will be more resource to provide community therapies” (Davie et al.,
2014:40). They then claimed that “20% of people on a ward do not need to be there for
psychiatric interventions” (Davie et al., 2014:40). This is despite a lack of data to support the
claim; in fact, the only data that could support this would be the delayed discharge metric that
senior managers in the Trust invented to accelerate discharges to the HTT, many of which
were rejected. Frank Keating and others have suggested that, for black service users, there is a
slightly different institutional cycle or “stalled cycle of recovery” from the one I have
described (Keating, 2016; Keating et al., 2002; Robinson et al., 2011). “People avoid mental
health services at all costs, then they come to the attention of services in a more severe state of
distress, receive coercive treatment; and when they are ‘better’, they disengage from services

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and the cycle repeats itself“ (Keating, 2016:176). The cycle Keating described counts on
service users disengaging from these services but, as I have shown, there is a case that the
services often disengage from them too quickly.

Service users who distrust the mental health system are already difficult to reach out to, build
a rapport with, and engage in a meaningful way. The lack of time for the HTT means that the
chances of a staff member (re)constructing that trust over a series of contacts with the service
user are very low, let alone repeating this process if the first team member fails to gain that
trust. Service users whose electronic records may indicate a tendency towards violence or
who fall into the stereotype of “big, black, and dangerous” can experience even greater
barriers to achieving a level of comfort and trust with the service to make progress (Keating,
2016). A history of violence in the electronic notes may, as the consultant suggested, affect the
length of stay with the HTT, though more research is needed to confirm this. Beyond this,
there is scarce time for staff to engage in reflective practice that might help illuminate their
preconceptions and help to eliminate the “big, black, and dangerous” stereotype. That staff
need self-reflexive practice is now an official stance of the Royal College of Psychiatrists,
though this falls into a familiar dichotomy of psychiatrists needing intensive supervision while
nurses, social workers, and support workers can just “get by” or “manage” (Royal College of
Psychiartists, 2018). To nurture practice that pushes back against racism and unconscious bias,
it is necessary to engage in a self-reflective process and this takes time, moments of calm, and
good supervision—all of which is in short supply in an overburdened mental health system.
Poor treatment in the mental health system also extends to immigrants and people of other
ethnicities whose lives have become harder in a post-Brexit vote world (Ryan, 2019).

Recent immigrants and refugees are less able to guard themselves from the effects of austerity
and are at risk of falling ill or becoming even more ill (Jannesari et al., 2019; Miani et al., 2017).
Those who are not on benefits making a minimum of money are also in an ever more
precarious situation. Many are unable to stop working to see the HTT which makes them
appear to not be engaging with the team. Others are unable to stay out of work for long or
prefer to live off their savings rather than claim benefits, leading to significant difficulties when

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they finally do have to start claiming benefits. Generally, if you are poor, you are less able to
do the things that might beneficially affect your mental health: for instance, pursue social
events, exercise, eat healthy food, and engage in activities that are conducive to good mental
and physical health. They are also often in substandard housing either with the council or with
slumlords, leaving them unable to effect change in their surroundings which can mean dealing
with mould, damp, cold, small spaces, high prices, and disrepair for long periods of time.

Throughout these experiences, those who are already on the margins of society or who are
rapidly being pushed into the margins through economic hardship are plagued by diminishing
expectations. There is little hope that more money will be invested into mental health care
when successive governments have promised money and never delivered. With ongoing cuts
to benefits, social care, public health programmes, and other aspects surrounding mental
health care, the expectations of those who rely on assistance and support can only be
diminished. This makes the emotional strain of austerity more and more prominent. The
retrenchment of the ability of the state to care for those with mental health issues has a
psychic impact. It generates a feeling within the individual that they are not worthy of an
investment of care by the state, that there are others who are more worthy.

During my research, it became clear that many individuals felt they had no claim over the
services they received, that there would always be individuals who would be sicker or more
deserving of home treatment then they were. This is a familiar dichotomy of the deserving
and undeserving poor, but it is played out within the mental health services: the deserving and
undeserving service user. There are of course, no undeserving service users—these people are
exactly the ones who need more time and attention. Not only are expectations diminished but
their own evaluation of their self-worth is diminished, as in their view, society does not see
them as worthy of investment, be it of care, sustenance, or even suitable living conditions.
Service users are being made to take the brunt of an economic crisis that ended years ago and
was not of their own making. Despite this, many now find themselves being pushed out of
their homes and communities. This actively breeds feelings of being powerless, not having a
say, and general disrespect, creating a vicious circle for some and for others a sort of “austerity

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blues”. Weaving this together to create a way of thinking through these conditions is difficult
but I do provide a model for doing so with the concept of a landscape of distress.

A Landscape of Distress
Why a landscape of distress? The landscape is increasingly important in the future of mental
health treatment as the centre of treatment is pushed further and further into the home.
Beyond this, the landscape of distress as a concept can help to build relationships between the
at times disparate elements of the social determinants of (mental) health, as well as
bioscientific and neuroscientific research (though I have opted not to do this in this research).
This concept can stretch beyond this research and be utilised to model service user experience
in cities across the world, especially those with HTTs. The way the HTT formulates service
users and thinks through this formulation can be thought of as a way to decode an individual
service user’s landscape of distress. The formulation takes a summary of the service user’s
main problems and difficulties working out how they relate to each other. The formulation
also includes an assessment of the individual’s relationship with their home, community, job,
environment, social life, and other aspects of their life, capturing most of the elements of the
landscape of distress. The formulation also carries with it a predictive element using
psychological theory to explain reactions to events, something which is not present within the
landscape of distress. The concept I am developing is one that can be thought through just as
formulation can.

The landscape view I took in this dissertation has its roots in the practice of the HTT,
Geslers’ Therapeutic Landscapes (1992), the social determinants of mental health (Allen et al.,
2014), and to a lesser extent, social science work on ontologies (Mol, 2002). The use of the
word “distress” goes beyond its psychological meaning: (1) It acknowledges the subjective
experience of distress that can be caused by a service user’s environment and social relations;
(2) It acknowledges the wearing down or enervating effect that an environment can have, just
as the word “distress” can mean age and wear; (3) It also recognises the use of the word
“distress” as a state of difficulty, such as when a ship is in distress; (4) Finally, the word
“distress” contains the word “stress”, a term which has provided something of a “gateway for

258
returning context to bioscience research” in terms of the impact of landscape (particularly
cities) on mental health and epigenetics (Fitzgerald et al., 2016). In the end, like a flag hung
upside down, it stands as a symbol of distress for the landscape it describes.

The idea of a landscape of distress is a nod to the multiple ontologies of Mol’s work (2002).
Mol peels back the ontological layers of medicine to reveal the multiple and sometimes
competing ontologies that are present, whereas I am making reference to the multiplicity of
lived experiences and understandings of a landscape of distress and the ability of the team to
formulate and model each of these landscapes of distress. It might appear as though I am
giving far too much credit to the ability of a mental health team to come close to an
ontological understanding of a service user’s experience. I am being charitable, in that the
team rarely is that in tune with an individual, but the ability of the team to comprehend the
service user’s psychological interpretation of events is one of the fundamentals of good home
treatment. Given the time and resources necessary, the team can use this to plan and engage
the service user in a way that helps them to cope with or affect change within their
environment. Without the time and resources necessary, the team is left identifying potential
issues and watching those issues take hold within the individual’s environment in recurring
stints with home treatment. The worry then becomes that the influence of the political
economy of care and successive loops through the mental health system begin to be identified,
as they were in the Madison studies (Stein & Test, 1980; 1985), as deficits and character flaws
that originate within the individual rather than emerging through an extended interaction with
a landscape of distress. Service users are not critically flawed because they are lazy or
somehow not skilled at living; rather the supports that help to create those conditions have
been withdrawn or were never in place to begin with. These are not undeserving people who
are in distress rather they are often underserved.

My development and use of the concept of a landscape of distress is not merely a repackaging
of the social determinants of mental health into a neatly accessible and flashy-titled bit of
academic jargon. The landscape of distress goes beyond this and it is worth stressing the
benefits of such an approach. In doing so, it is also important to note that “a list of social

259
determinants of health that is recognised as authoritative does not exist in the same way as (for
example) a list of the risk factors for cardiovascular disease” (Schrecker & Bambra, 2015:7).
The idea that there is a therapeutic affect to landscape, that a landscape both physical and
human can have a positive impact on health, is well established and crucial to the
understanding of how a landscape might have a negative effect on mental health (Baer &
Gesler, 2004; Curtis et al., 2013; Gesler, 1992; 1996; 1998; 2000; Gesler & Curtis, 2007;
MacKian, 2008; Wakefield & McMullan, 2005; A. Williams, 1998; 2009; Winchester &
McGrath, 2017). We know that there are various aspects of living in cities that create ill
mental health in some way, whether it be through exposure or stress, or by migration towards
centres of treatment excellence, all of which are at play in Lambeth to some extent
(DeVerteuil et al., 2007; Fitzgerald et al., 2016; Krabbendam & van Os, 2005; Lederbogen et
al., 2011; Luhrmann, 2007). There are many different social determinants of mental health that
affect those who live in Lambeth, but there are also a set of political and economic
determinants of mental health at play, as Ted Schrecker and Claire Bambra would point out
(2015). Bambra’s political economy approach “focuses on ‘social, political and economic
structures and relations’ that may be, and often are, outside the control of the individuals they
affect: health is politically determined“ (Bambra et al., 2005; Schrecker & Bambra, 2015:8).

Taking health as politically determined and acknowledging the lack of power individuals have
to remove or raise themselves up from troubling situations, often leaving them in a state of
distress, helps to adjust our view of the experience of such social determinants of mental
health as one that is distressing, that wears on individuals. Using the lens of the landscape of
distress also aids in tracking the manner in which austerity or public policies affect mental
health in a way that goes beyond basic statistical measures. How might one measure the
landscape of distress? Are there statistical measures that can capture the topography of the
landscape of distress? Data needs to be gathered on the speed with which service users move
through the mental health system and the frequency of their relapses, along with the social
determinants of mental health within the area to develop a picture of the landscape. Armed
with this, one can then determine whether the landscape and the local mental health system is

260
contributing to distress, as well as isolate various aspects of this which can then be intervened
upon.

Home treatment and landscapes of distress are becoming increasingly important with the drive
to re-centring treatment within the home. With the continued emphasis on treatment being
delivered in the home, there will be a certain spatialisation of experience, distress, and
treatment. There are consequences to this that are only beginning to be realised. Service users
are increasingly isolated within their environment, especially if they fear places or other
people. Homes are often taken for granted as places of refuge or comfort. A home is not
always a happy place or even a place that might be repurposed as therapeutic. The other
people who live in these homes are often not consulted on the return of ill family members or
roommates. Sometimes the home has not been visited and is not fit for habitation. All of this
can lead to conflict and the failure of treatment plans. The retrenchment of housing benefits
and the often dilapidated state of housing may mean that by (re)centring care in the home, we
are exposing or continuing to expose service users to undue distress and potential health
problems. If teams like the HTT and others do not have the time or resources to effect change
in these homes, then service users are being condemned to conditions that might end up
resembling those detailed at the turn of the 20th century, in Maude Pember Reeves’ study on
working class families in Lambeth (Reeves & Alexander, 1913). In short, the quality of care
will be determined in many ways by the quality of housing and environment, as even the best
care will be defeated by a truly distressing landscape/home.

Austerity, Affect, and a Cruel Optimism

The relation between austerity and mental health is not a new one. The crisis that is
publicised in the media about funding in mental health and the NHS seeks to draw attention
to issues that are merely normal aspects of the field. When I focused on the practice of the
team, I was focusing on how that practice changed in small ways and how this was related to
the slow drain of resources and time. This process itself is one that is imbued with ordinariness;
in fact, much of what I have covered in this dissertation highlights what is a historical process
of adaptation to ordinary conditions of austerity within mental health services. A landscape of

261
distress does not appear overnight; it slowly takes root, growing over time like the mould
spores and damp in many of the council homes I visited. The process of change that occurred
in the HTT was one of adjustment; the difficulty with this adjustment came when it embraced
a “cruel optimism” (Berlant, 2011).

Lauren Berlant argues that “cruel optimism exists when something you desire is actually an
obstacle to your flourishing” (2011:1). There is an inherent optimism contained within the
team’s new process-first model of moving people through the team quickly that constitutes a
cruel optimism. For instance, in order to open up space to do the meaningful and impactful
work that allows the team and its service users to flourish, the team concentrates on moving
people through the service quickly. This service model relies on the premise that there will be
time to do this meaningful and impactful work; however, the Trust has shown that any excess
capacity created is immediately used to reduce the use of beds and thereby the cost of care.
The process first model then becomes an obstacle to the team and their service users’ ability to
flourish. The nostalgia present within the team and the anxiety around speeding up and
moving people through quickly are merely side effects of this cruel optimism, as identified by
Berlant (2007). This is not the only place where I found evidence of such a cruel optimism.

The crisis that many service users are in is often a crisis of adjustment or maladjustment to
their surroundings, their medication, their relations with society, and, as Berlant points out,
their notion of a “good life”. The difficulty with the recent austerity is the way that it comes
together within service user lives in new configurations that ultimately construct a landscape
of distress. As these distressing elements coalesce, they are not necessarily encountered as a
crisis but rather trigger a mental health crisis because of the process of adjustment to a new
ordinary. For instance, one of my participants stockpiled tea and other items in response to
being moved off a disability benefit. He was not driven into crisis by the WCA but rather by
the vision of what his new normal would be and how he would adjust to this. The anxiety
around the situation made things worse and there was certainly a point at which things came
to a head, but the instigator was the adjustment to a new ordinary. There is a cruel optimism
at work here.

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Service users turn to the benefits system for aid and support in order to stabilise themselves
and look to a future where they can gain employment and flourish. The difficulty is that the
benefits system is often what keeps them from achieving these goals and flourishing. The
consistent friction and anxiety that it adds to their lives in the form of poorly thought out
policies of “nudges”, punitive actions, or threats of punitive actions, is the very opposite of the
support they require. Providing substandard accommodations for service users can often
become a source of illness and stress rather than a place of refuge, contributing to the cruel
optimism experienced by turning to benefits for support. The sheer ordinariness of the
difficulties that those who fall into poverty—now one fifth of the population—face from the
benefits system and the social supports that are in place to help people lift themselves out of
poverty is stark (Alston, 2018). This is a system that is particularly difficult to navigate for
those who are affected by mental health difficulties, something that other researchers have
pointed out is akin to Berlant’s sense of “slow death”, the state-managed wearing out of the
bodies of workers and the disabled alike (Berlant, 2007; 2011; Goodley et al., 2014).

From afar, it does appear as though the landscape of distress, in part manufactured by
government cuts, inflammatory rhetoric about the deserving and undeserving poor, and other
factors, is being managed to slowly wear down or distress a population of workers,
former/future workers, and disabled people. That existence outside the relations of capital and
labour is one that can only lead to increased hardship, mental and physical health difficulties,
and an accelerated demise. The 2008 financial crisis and ensuing austerity programmes have
come to reveal life on the margins as conditional itself. People must meet the conditions the
government sets in order to continue to engage in a cruel optimism. Surrounded by this,
mental health service users internalise the conditionality that exists all around them. Out of
this has come an “austerity blues”, a reaction to receiving help whereby the person thinks that
they actually should not be receiving help because resources are so low and there are other
people out there who need help more. This is an active devaluing of their own experience that
feeds into the cruel optimism produced by the landscape of distress and also the actions of the

263
government that reflect back on their lives as not being worth investment, help, or care. With
that being said, where is the role of the HTT in this?

The HTT is perhaps the future of mental health care as it pushes further and further into the
home and the UK catches up with its responsibilities as laid out in the Convention on the
Rights of Persons with Disabilities (CRPD). It is also uniquely able to deal with the landscape
of distress as team members are consistently entering peoples’ homes and are able, when they
have time, to help deal with some issues and to chase other services to deal with longer term
issues. That being said, it is more and more difficult for the HTT to achieve this within the
constraints they have on time. The team is also uniquely placed to have some effect of the
conditions of cruel optimism that service users live in, as they can and do act as sounding
boards for service users to develop a better understanding of how their living conditions and
relationships can be improved or broadened. Part of the work of home treatment is to open up
the landscape in which the individual exists and to expand their horizons; for instance, they
can work with service users to help them go for walks or shopping outside of their home,
helping them build confidence and expanding the landscape in which they live. The Trust
plays a large role in how far the HTT can go in terms of their ability to create change in
service users’ lives.

The current direction of the Trust’s policy on home treatment places the team within the
binds of a cruel optimism, as they are forced to move service users on faster, in order to clear
time for more intensive work which is often negated based on the emphasis on speed. On the
level of the Trust, their attempts to create more capacity in the system by increasing the speed
at which people move through the system is also a relation of cruel optimism. By increasing
the speed at which service users move through the system, they limit the abilities of their
services to affect real and lasting change in service users’ lives and thereby increase the rate at
which service users relapse. Ultimately this creates more demand, defeating their attempts at
creating more capacity. What then are the answers? Slowing the institutional loop? Disrupting
the landscape of distress?

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The mental health system needs to look at individuals across their life-course. If it makes sense
to make changes and fix problems now that will save the individual anxiety and potential
relapse in the future, then those changes should be made in the present. The difficulty with
this is the corresponding issues that remain out of the remit of the mental health system to
affect change. This is perhaps why, as one psychiatrist told me, “all psychiatry is political”. To
paraphrase Bambra, “all mental health is political”. For psychiatry to truly succeed beyond just
managing symptoms and relapses, it needs to affect change in a number of areas within the
lives of service users. Nowhere is this more clear than in the home visit. The difficulty with
this is the sheer ordinariness of the difficulties that mire many service users in lives where mere
adjustments to the ordinary hardships they face can be considered feats of immense difficulty.
As I told one woman with whom I spoke, the fact that she had been able to come as far as she
had with as much difficulty as she had faced stood as a testament to how good of a person, a
mother, and a partner she was, regardless if she felt she was “a bit shit” for not being able to
provide all of the accoutrements of the good life to her children and self.

A Prescription for Mental Health?

If “all mental health is political”, how might policymakers, social scientists, and psychiatrists
work together to create better mental health, and what lessons revealed in this dissertation
might then be applied? If we begin from the standpoint that all mental health is political, that
all economic and social policies have some effect on mental health, and that this effect should
be ascertained before the implementation of policies to avoid undue strain on the mental
health system and the mental health of citizens, then we need a model for how to approach
making policy that supports mental health. Stuckler and Basu argue in The Body Economic: Why
Austerity Kills that economic policies should be evaluated for their health impacts in much the
same way as clinical trials evaluate novel drugs (2013). A clinical trial for economic policies is a
great idea but would require a massive change in the way governments design policy.
However, there is a process being used to adjust policy in developed countries and it could be
reshaped for similar purposes.

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I propose, as a general approach to improving mental health services and creating a
therapeutic landscape that benefits mental health, that governments should institute a
mental/physical health-based analysis. This would operate much like the current gender-
based analysis/+ of government policies in countries like Canada, New Zealand, and Sweden
(Scala and Paterson, 2017). Gender-based analysis examines each policy that is proposed or
planned by the government and works to assesses the way that women, men, and non-binary
people might experience policies or programs (Scala and Paterson, 2017). Countries that have
socialised medicine should be focused on producing policies that protect and improve health to
reduce the operating costs of healthcare. In screening every policy at every level of
government for potential effects on mental or physical health, they can avoid producing a
landscape of distress and take pressure off current mental health services. The model for doing
this already exists in gender-based analysis/+; however, the process has been criticised as
reactive, failing to create and lead the way on policy, and instead only vetting existing or
proposed policies (Bacchi, 2010). To have a significant impact in the UK, this analysis would
have to be proactive; to this point, I have laid out some broad policy guidance based on my
research below.

My research has revealed that a Mental Health Trust, along with other levels of government
take a reactive position when it comes to redesigning the mental health system to produce
efficient treatment and expand capacity without substantial increases in funding. Though the
Trust claims to be proactively finding solutions to difficulties that it identifies, I have shown in
chapter seven that their strategy is one that reacts to the immediate concerns of the day to day
operation of its’ mental health services. What this results in is a process of redesign that in its
implementation redefines what the word “crisis” in “crisis care” means. I believe that the Trust
needs to first begin by defining what a “crisis” ought to mean and then work to make their
system reflect this on all levels. This would set the balancing act between too many or too few
beds aside and allow the Trust to examine other aspects of the service that can be adjusted,
perhaps most important of which is the time horizon of their services.

266
The current way of tightly managing bed days and time spent in the mental health system
keeps services like the HTT or other CMHTs from acting decisively on issues that bring
service users back again and again. A concerted attempt needs to be made to unravel the
figure eight that such a short-term focus creates. In expanding the time horizon and allowing
for the careful application of “a tincture of time” in treatment, the Trust can begin to address
the difficult dichotomy currently at the heart of the mental health system. This dichotomy
between caring and process already pulls the HTT (and no doubt other services) focus on
deciding who might need extra care and who might not, which results in an active rationing of
care. This gives the HTT flexibility to ration care based on the needs of the service user and it
must be retained and defended to produce a more effective crisis service. However, mental
health teams need to be able to apply a concerted focus towards addressing issues in service
users lives that keep them from recovering. This cannot be achieved without curbing the
acceleration present within the system. We must give the mental health teams time to effect
change in peoples lives. Doing so will go a long way to address other important issues, like
understaffed wards, that lead to the quick use of restraint. If wards and teams are properly
staffed and are not pressed for time, not only will they use strategies that take more time like
de-escalation, but the use of restraint will decrease and the environment will become less
disruptive, ultimately leading to increased staff retention. Standing in the way of this is the
Trusts’ new focus on data as a way of solving capacity issues, which threatens to increase
acceleration and remove the ability for teams to navigate the difficult dichotomy of care versus
process.

A data-driven base for decision making is problematic at best, as I have mentioned in this
chapter, but it also prevents the team from engaging in conflict with the system to produce
better outcomes for service users. If the data says one thing and the team says another the
Trust will rely on the data (as I have shown in chapter 7). The immediate goal of the trust
should be to find ways to increase the amount of time for home visits by developing and
implementing a simple data-based algorithm to aid in the allocation process. This algorithm
would create time by drastically shortening the allocation period in the mornings/afternoons
and maximizing the time of team members by allocating them to the most efficient routes to

267
visit service users. This is an example of a data driven process that creates time in a way that
does not displace the autonomy of the team. There are other options to create time for the
team, but careful and judicial work needs to be done to ensure that time also remains for
personal development of nurses, support workers, and social workers. Unfortunately,
developments have begun to shift the mental health system towards a pay by results (PbR)
tariff which would reward mental health trusts for finding ways to sidestep service users who
need more intensive engagement and longer stays in acute services.

The development of PbR would lead to significant changes in the quality of services for black
and other ethnic minorities, who typically have longer stays and would thereby be considered
less profitable. This again is approaching an important issue in the opposite way; if money is to
be saved, then it can be saved by addressing the underlying reasons why black service users
tend to have longer stays and working to find a solution to bring their length of stay in line
with other service users. This policy threatens to incentivise Trust’s to simply accelerate these
service users through the system instead of addressing why they have longer stays in the first
place. Part of this readjustment demands a renegotiated rhythm to the mental health services
to reduce the potential for acceleration to affect marginalized populations. All of these policy
implications need to be supported and encouraged by the government through a landscape-
based approach to policy for reducing mental health costs.

The government needs to take a landscape view of mental health and begin to shift its policy
decisions towards dismantling what I have called the landscape of distress. The first step must
involve reinvigorating NHS mental health services in a very public and transparent way; the
government needs to show people suffering from mental health issues that they are not
second-class citizens and that they are worth the investment. The public needs to be
confident about the importance of good mental health, and the government needs to show
that it is dedicated to creating policy that supports the NHS both directly and indirectly. Even
the best care cannot help people recover if they live in a system that does not give them the
support to recover. Take, for instance, the lack of after-hours coverage for people who retain
paid work and are seeking treatment for mental health issues. This encourages people to drop

268
out of paid employment to seek care, and with the new universal credit system that delays any
payment of benefits, it creates a situation that will actively work against the best efforts of
acute care teams like HTT to aid in a swift recovery and return to work. Without a concerted
effort to develop a landscape that is supportive of mental health, even the best package of
funding will fail to stem the tide. Perhaps most important in this effort by the government to
create confidence in service users and address the crisis within the mental health system is a
need to find a way for people who live with severe mental health issues to exist outside of the
productive relations of capital without being treated like a burden on society. There are
multiple ways to add value to society and creating pressure on those who are suffering the
most to be productive members of society can be done without forcing them into zero-hours
contracts and temporary low paid work. Such an approach pairs well with recent calls to use
other methods to determine the wellbeing and growth of countries besides measures of Gross
Domestic Product. Society desperately needs to find a way of valuing something other than
pure economic growth.

What Can Social Science Do?

There is a role in this for sociology and anthropology to play, and this role should concentrate
on the intersection between the home and care. This is clearly the future of care, not just in
the UK but around the world. It also happens to be a place that black boxes the treatment and
care for those who suffer from mental health difficulties. Entering the home carries with it a
host of difficulties as researchers, but it is of the utmost importance that we, as social scientists,
follow the nurses, social workers, and psychiatrists into these spaces and develop concepts and
theories that help to render visible the processes which occur in these places and the ways in
which these practitioners think about, work in, and interact with the service users in their
homes. More research is needed to explore the impact of HTTs on NHS mental health trusts
to understand their place within service redesign. I have made a clear argument here that they
are being used to manage austerity policies, but there has yet to be enough supporting
evidence to show this is the case across the country. Clearly, when it comes to arguments
about effectiveness, and what some might call “soft findings of patient experience”, the HTT

269
is the way forward. That being said, the most important factor involved in HTTs’ growth as a
service is ensuring that they have the time to visit individuals and attend to the “granular
aspects of care” that contribute to a truly therapeutic encounter. Social science can support
this while expanding its role in conjunction with psychiatry, as was the case in early work on
the Amsterdam service which was done by sociologists and psychiatrists together (Lemkau &
Crocetti, 1961). Time, space, place, and practice should be the focus of this work as they can
lead to new and insightful ways of illuminating the inherent difficulties that mental health
services have in struggling to provide a quality service with limited resources.

270
Appendix

Home Treatment Team Consent Form – Participant Observation

Home Treatment Team Consent Form – Qualitative Interview
Service User Consent Form – Participant Observation
Service User Consent Form – Qualitative Interview
Home Treatment Team Participant Information Sheet – Participant Observation
Home Treatment Team Participant Information Sheet – Qualitative Interview
Service User Participant Information Sheet – Participant Observation
Service User Participant Information Sheet – Qualitative Interview
Service User Interview Schedule
Team Member Interview Schedule

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