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An alternative method for community health services




People generally know what they are doing, they generally know why they do what they do.
However, they rarely know what is done by what they do.
(Pierre Bourdieu)


The history of acute psychiatric methods of treatment in Norway, as in many other European countries, is long and painful. In the past, cases of acute psychiatrically disturbed patients were met mainly by hospital admission and medication. After only a brief interview a doctor had to make very important decisions concerning the person’s future. The treatment usually consisted of hospitalisation, medical evaluation and physical restraint, while the investigation of what was considered necessary and appropriate medication, was quickly decided by a psychiatrist. Even though this kind of response to severely disturbed patients at times may have been efficient in protecting society, it was also experienced as traumatic by many patients and their families; considering that the danger of developing a chronic illness while admitted to psychiatric institutions is a well-known fact (Basaglia et al.). The downsizing of psychiatric care units followed, which in turn has led to public criticism of the inadequacy of treatment facilities.

In Norway, as in many other countries, alternatives had to be found. The importance of avoiding admittance to psychiatric hospitals has become an important issue. An awareness of a need for an alternative, which would avoid the usual consequence of the downsizing of psychiatric care units, namely abandoning psychiatrically disturbed people, leaving them without the assistance necessary for their daily survival, increased.

As a result, the new methods of treatment evolved; people had to be helped in their home environment and the psychiatric problems were to be resolved in the context of patient’s daily life.

To give support to a disturbed individual in crisis situations, it is necessary to: 1) organise a decentralised service, which mobilizes the family and network as well as professionals involved in the case. By establishing a dialogue and cooperation among those involved, new ideas can contribute to several options for resolving the acute crises. Another important factor is that the help to those in psychological distress must be easily accessible close to people’s homes. 2) A team of social workers of varying background should be established and trained. For example, the team established in Norway (Follo Clinic) is open to anyone in a need of psychiatric help. Initially no reference from a medical practitioner is required. A written reference letter may be received after the first consultation. Otherwise applications can be accepted directly from the client, family, friends, workmates, the police or others in the community health and social apparatus. The first contact consists mainly of listening to what is presented as well as encouraging as many members as possible of the identified patient’s network to attend. It is important that all the parties involved have a chance to present their version of the story. The second contact or discussion involves a decision about whether the crisis team is the best option available for the patient or if a further referral to somewhere else would be more appropriate. Telephone contact may also be established with colleagues who are already familiar with the patient or the family. After only one phone call the contact with the client may end in cases where the situation had stabilised.

THE TEAM INTERVENTIONS take place when the team accepts the application for help, when the case is registered in the system. Basic data is collected on the registration form; the identity of the caller and the patient are registered together with the patient’s address, phone number, source of income, civil status, age, type of abode, name of GP, network, as well as previous hospitalisation or other treatment. If the application is on behalf of someone else, the question of whether the defined patient is aware that the team has been contacted will have to be raised. It is important that the team maps the course of events that led to the actual contact with the psychiatric service, and it is important to ensure that all the involved parties have been taken care of. The team then discusses the information obtained in cooperation with the clients.

Already during the first discussion on the telephone the caller is informed that the case will be discussed by a group of colleagues at the clinic before any answer can be given. If the case accepted, the person/family is given a new appointment within 24 hrs of the first contact. The time it takes to give a new appointment depends on the seriousness of the situation and the capacity at the clinic. There are several reasons why it is important to let some time elapse before the second contact is made. Either the patient or relatives in crisis make the first call. Many of the conversations are coloured by strong emotions that affect the team members. Experience has shown that the team members need some time to digest what they have heard and gather suggestions, ideas from other colleagues. Otherwise the staff may be tempted to be too helpful too soon and become part of the patient’s problem, by not being able to stand aside and use the necessary time for reflection. The team must be flexible in their reactions to crisis situations; the team must not separate the problem from the patient. Another important function of the initial telephone conversation is to seek the acceptance for contacting other help instances in the district.

Before the team-worker calls the concerned party back, the application is discussed with other members of the team and the doctor on duty. The patient’s GP or other community services involved in mental health investigate the possibilities for treatment e.g. specialist teams for psychoses, workers specialising in drug/alcohol abuse and geriatric services. Previous treatment contacts are followed up. Decisions have to be continually reviewed, and discussions as to who is to be involved in the follow up, or if indeed the clinic should be involved in the case at all, are essential for this process.

The team’s response

Respons is given in meeting with the defined patient as often as possible, together with other persons involved. If the application for help was made on behalf of another family member, the person in question is included in the first meeting with the others involved. This also applies when the application is made by the GP, the communal health service or other possible partners. Before deciding on the best course of action, the team wants to meet the patient with the instance(s) that expressed their concern. The team may offer to come to a doctor’s office to meet the patient together with him or her and offer assistance in making an evaluation. The team members can provide conversations in private homes if needed. It is important to meet people in their ordinary social environment, often with others who are acquainted with other aspects of the client’s situation besides the acute crisis. Persons involved are often able to frame the crisis in more clear words than what is possible for the team to achieve in a clinical setting. For the anthropologist Clifford Geertz’s «other cultures», as for instance a family, cannot be understood fully. Through communication with several persons, one is able to observe the parties from as many angles as possible. Thus one may be able to achieve a broader and deeper understanding of the situation, and at the same time perceive the many layers of meaning of which the situation consists.

Where one chooses to meet varies according to what is most convenient for the patient and according to what generates most relevant meaning for the patient. If one will have to make a judgment about admittance to hospital or medication, an appointment is made for meeting at the clinic. The team has its own office for meeting patients together with the doctor who is on call. The doctor is seldom able to leave the clinic. There has been a debate within the team of whether it is a good idea that the doctors at the clinic are responsible for supplying the team’s patients with medications, especially when treatments of long duration are concerned. Recently the practice at the clinic frequently recommended patients to use their GPs. The specialists-doctors at the clinic may in these cases serve as advisers to the GPs who may feel the need to discuss cases. The GP is often familiar with the history of the patient before the actual crisis, and they may be of assistance over a longer period of time. This is also a good opportunity for the team and the GP to engage in a concrete dialogue and cooperation across different specialities.

The first conversation with the team

There are usually two members of the team present during the first meeting with the patient. One team member may be enough if the meeting takes place at the GPs office or with a partner the team can cooperate with. It varies whether and to what degree a conversation is organized and planned beforehand. The team members try to attend the meeting without preconceived ideas, especially if another mental health worker organizes the meeting. Otherwise one works according to a prepared hypothesis. If Andersen’s “open reflection” is employed, an agreement concerning the role of each team member is often agreed upon beforehand. One team member leads the conversation, asks questions and gives answers on behalf of the team. The other team member has the role of a listening observer and contributor of reflections when needed. Roles are changed as to who leads and who reflects. The team member whose task is reflection may act as a discussion partner to co-workers after the meeting and she/he may also engage in evaluation of the therapeutic process. Previously the work has been conducted in co-therapists setting, i.e. co-workers being equally active during the conversation. The reason why this has been changed is insufficiency, which resulted from confusion that would occur.

At the beginning of a conversation it is important to explain whom the team consists of, how they can contribute and how much time is available for the conversation. The usual time frame is one hour. It is very important that everyone who wants to say something is able to do so and that those who do not wish to speak are excused. In conversations where many people are present, the format described in Seikkula’s “open dialogue” may be useful. One often conducts a round where everyone can present their thoughts about the situation, and the expectations they have concerning the meeting. In closing, one again makes a new round in which the different parties may say what they think about the conversation that had taken place and what they can do to relieve the situation. The role of the team members is to lead the conversation so that a dialogue is possible and that emotional responses do not stop the dialogue. During this work the therapists may freeze the conversation and reflect aloud together with other participants about the themes that have come up.

The methods are used interchangeably, and the structure is not to be determined in advance. The main objective of the conversation is to open the dialogue between the parties and give them the possibility to change or see the new perspectives. Achievement of consensus is not the ultimate goal of finding new possible solutions. It is more important to emphasise differences and to make disagreement less dangerous. The team has been delegated the task of judging the crisis in relation to psychosis, suicidal tendencies, and whether the client may be of danger to him-/herself and others (Sosial- og helsedepartementet, 1996).

There are several reasons why it is important that the family and network participate in the conversations. Once the problem is taken out of the immediate network, those involved have usually experienced a situation, which has been stressful over a long period. The people around the patient are often exhausted, extremely worried and scared. When someone slips into a state of psychological disturbance, the situation will be experienced as incomprehensible and frightening. Most people do not know what to do or what can be done to change the situation. Often several family members or the entire network may be in need of help and support during the crisis that involves them. It is essential to provide those surrounding the identified patient with an understanding of what is happening and how they may support one another as part of a new pattern of cooperation. Otherwise individuals involved may easily become «adversaries», both to each other and to the treatment staff. At times the defined patient never appears, and the work is to a larger degree directed towards those comprising the persons network.

 Further follow up from the team and preliminary results

During the conversation the participants develop a plan for the further work. Some persons may be followed up over a period of maximum four weeks. Individual or family conversations may be schedule as frequently as necessary until the crisis in question is resolved. The team may agree to keep in touch via telephone, they may schedule regular meetings, or the person may call the clinic when needed. People are asked to contact the team and not vice versa. The team worker may, when needed, assist in the formulation of an application for further treatment to other treatment teams. The team is the link that may apply for help from the communal health service, the family therapy office and the GP. It is usual to assist with a variety of themes such as help in relation to social life, economy, dentist, prison etc. The team creates a crisis plan in cooperation with those who are in charge of care, and with the person concerned.

A CONSIDERABLE part of the team’s work is to mobilize the help as well as to cooperate with other help services in the region. Some patients may need help and support for longer periods of time than the team is able to offer. The acute team is a service, which is mobilized and used for short periods of time for acute handling of the critical situations. During the less critical phases the team may function in the background as a safety net. The team and the community health services continue an active follow up, ready to handle the new developments as they occur.

The ADVANTAGE of meeting people in their own environment makes it easier to use and discover more positive qualities of their lives. Meetings in the GP’s office may prevent reducing the difficulties of life down to «psychic illness». In addition, available care units are important backup. Short-term voluntary hospitalisation enables the team to offer some temporary relief in a safe setting while the patient remains in the local community. It enables him or her to receive visits from both family and friends and makes it easier for the patient to keep in touch with his or her regular therapist. Most of the applications are about judging the danger of suicide, psychosis and serious sufferings. Parents of small children and patients who have been treated earlier or having been admitted to acute psychiatric wards before are given priority. The team is an adult psychiatric unit and does not receive applications from persons under the age of 18. It is considered advantageous to meet any of the children involved, as it is important to talk to the children in the family. In some cases advice from child- and adolescent psychiatric policlinics or other relevant units is sought. The team sometimes assists with arranging sick leave for others in the family or the network and providing medical assistance for a shorter period of time.

The Positive Response the team had received, especially from the patients, consisted of stressing the appreciation of quick intervention and accessibility. The patients particularly emphasize the fact that someone is always available for a contact in the evenings and at the weekend, and that there exists a telephone help line during the night. Several patients stressed the importance of knowing that there is someone out there that can handle their situation whenever needed. Patients feel that the availability of information about the team and the team conversations are also of a great importance to the functioning of their own network. They appreciate the fact that the GP and the community health service are informed and can take over afterwards, this being the result of the team providing counselling and advice to the GPs  and the Community health service.




Andersen, T. (1991). The reflecting Team: Dialogues and Dialogues about the Dialouges. New York: Norton

Basaglia, F. (1981). Breaking the circuit of control. I.D. Ingleby (Ed.): Critical Psychiatry. Hammondsworth: Penguin

Geertz, C. (1973). The Interpretation of Cultures. Basic Books, Inc, New York.

Seikkula, J. (2002) Monologue is the crisis Dialogue becomes the aim of Therapy. Marital Fam. Ther. 28: 283-4

Sosial – og helsedepartementet. (1996a). Åpenhet og helhet. Stortingsmelding nr. 25, 1996-97.


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