An alternative method for community health
services
A REPORT BY KIRSTI BAIRD
HULTBERG CLINICAL ADVISOR, ACUTE TEAM AT FOLLO CLINIC
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 teampresent 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 GPsand the Community health service.
References:
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.
