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AUTHOR: ROBERTO MEZZINA & DANIELA VIDONI
TITLE: BEYOND THE MENTAL HOSPITAL: CRISIS INTERVENTION AND CONTINUITY OF CARE IN TRIESTE. A FOUR YEAR FOLLOW-UP STUDY IN A COMMUNITY MENTAL HEALTH CENTRE
SOURCE: The International Journal of Social Psychiatry v41 p1-20 Spr '95
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PUBLISHER ABSTRACT AB A sample group of 39 new patients with acute and severe crises underwent a 4-year follow-up study at the community mental health center in Trieste (CMHC). The CMHC is a full- time service, open 24 hours a day and 7 days a week, and is fully integrated into a network of services which has completely replaced the preexisting mental hospital. Evaluation shows: 1) a generally good outcome of the initial crisis; 2) a low relapse rate; 3) a tendency towards favourable long-term outcomes. In terms of practice, voluntary and compulsory hospitalization were avoided in favor of short- term day and night support in the CMHC. There were no suicides, no crimes, no drop-outs. Social adjustment remained unchanged. Accessibility and continuity of care were favored by not separating special crisis services. Instead, crisis intervention was integrated into a comprehensive Mental Health Service offering a wide range of preventive and rehabilitative responses. The study demonstrates that the mental health services in Trieste are able to cope with acute crises without psychiatric hospitalization.
INTRODUCTION
CRISIS AND THE PSYCHIATRIC CIRCUIT: THE RISK OF EARLY INSTITUTIONALIZATION
A number of theories describe crisis as a positive opportunity, an event which has the potential to bring about transformations (Lindemann, 1944; Caplan, 1964). Even in the case of psychotic crisis there is the possibility of a "growth experience" (Jackson & Watzlawick, 1963). But this concept of crisis, which seeks to reassess mental illness by investigating suffering in the individual's life, is often denied by intervention philosophies which immediately codify the crisis according to restrictive medical- psychological models and related practices which aim at containing and controlling it.
We stress that any definition of crisis must ultimately take into account the psychiatric organization in a given place and time. It must be kept in mind that the patient moves within a "circuit" made up of all the institutions that can treat, reject or direct him from one to another. The types of treatment and philosophy which are present create a context that influences the phenomenology of the onset, course and outcome of a crisis.
A current understanding of the term "crisis" in psychiatry is mainly linked to the idea of behavioral problems and, ultimately, to social threat or danger. Crisis thus tends to be identified with the reasons of social control which bring the individual to a psychiatric institution. In this sense, a crisis is seen mainly as an "emergency" or, considered in its microsocial implications, as a "social emergency" (Hankoff, 1969).
Due to its connection with problems of social order, the treatment of acute cases is often influenced by extra-clinical variables and usually implies the patient's hospitalization, with frequent recourse to compulsory health treatments (CHT).
An individual in crisis generally enters a psychiatric circuit in which the mental hospital is (and was in Italy before the reform law of 1978) the last resort. The hospital thus not only affects the threshold of crisis recognition (Katschnig & Cooper, 1991), but also infects the community as a "social germ" (Maccacaro, 1978).
Several authors underline the regressive aspects of any preconceived and nonindividualized response to crisis. Often the moment in which a person in crisis receives attention can be identified as the point of greatest simplification (Dell'Acqua & Mezzina, 1988). The individual has already gradually simplified and reduced the complexity of his suffering to a set of symptoms to which only psychiatric services are usually equipped to respond (Basaglia, 1987).
Also short-term hospitalization in acute units can expose the individual to a risk of cutting the ties with his existential context. Once experienced, it could become an easy way out both for the patient and his environment, thereby "inducing" relapses. It tends to enclose the suffering experience in a "mentally ill role", which often crystallizes it and facilitates chronicity (Asioli, 1984; Scott, 1967).
In our opinion, community services must be conceived as alternatives not only to reclusion in the asylum, but also to those methods inherent in a medical model of psychiatry which "contain", reduce and impoverish the patient's experience or deny the importance of working with resources present in their environment. At the same time, they must be able to work out its micro-social conflicts.
In this context, crisis intervention services generally use quick, early methods of intervention aimed at an immediate solution to the problem outside of the psychiatric circuit (Aguilera & Messick, 1982). The various kinds of domiciliary crisis intervention are usually aimed at less severe psychiatric pathologies in the framework of "primary prevention" (Caplan, 1964) and specifically seek to reduce the number of admissions to mental hospitals (Ratna, 1978; Levinson et al. 1992; Reynolds et al. 1990). In any case, such services remain tied to hospital-centered systems, at least as far as mobile units are concerned (Gillig et al. 1990; Chiu & Primeau, 1991). After the pioneering experiences of the noted Querido's service in Amsterdam (1931), of Vienna in the late 1940s and American examples dating from the 1950s, the 1970s saw a European development of "crisis services" in such places as Groningen, Laibach, Reims, Linkoping, West Berlin, Belgrade, Munich and Budapest (Katschnig & Cooper 1991; Katschnig et al. 1993; Brandon, 1970; Hafner, 1974; Lim, 1983).
Several classifications of crisis services have been proposed. Ratna (1978) defines as "specific" those services which cope with specific problems (grief, sexual assault, addiction, etc.). Included in this category are self-help groups and "hotlines", which are often developed by associations and non- institutional organizations. "Non-specific" crisis interventions are provided by GPs, social workers, casualty departments (emergency wards) and police. "Central" or walk-in services respond to those seeking help in or outside of hospital facilities. "Comprehensive" services are Community Mental Health Centers (CMHCs) providing crisis intervention as part of their practice. In this sense, a forerunner of the 24 hour CMHC is to be found in the US Community Mental Health Centers Act of 1963, during the Kennedy Administration.
Katschnig and Cooper (1991) identify two kinds of services according to the type, or how and where, of contact (direct, one-to-one contact, or not; fixed or mobile). The degree to which a service is labelled as "psychiatric" can carry a stigma, with possible risks for a patient's career.
A service's case-screening procedures and lack of after-care has a definite impact upon the global effectiveness of acute state treatments. Demand selection is closely related to the question of separate and specialized crisis or emergency services vs. comprehensive ones, which provide such assistance as part of their practice. By tending to select cases, the former lose the ability to be strategic checkpoints for the demand in a specific area and thereby counteract hospitalization in its various forms (Birger et al. 1974; Fisher et al. 1990). In any case, despite their different aims and philosophies, both kinds of services must cope with a mixed demand of both "crisis" or forms of psycho-social distress, and acute psychiatric illnesses (Katschnig & Cooper, 1991). The W.H.O. first field study and report in Europe (Cooper, 1979) has clearly identified a "continuum" of psycho-social and psychiatric emergency services throughout Europe, with a gradual shift from "medicalized" hospital-type services (emergency wards) with more rigid structures, to flexible community services based on teamwork and crisis intervention approaches.
Providing short-term, non-institutional recovery facilities is also crucial. Where these alternatives are not available or time-limited, the assessment of risks inherent in leaving the user in his environment often leads, after a frustrating process of gaining time, to hospitalization (as for two-thirds of "CPOA" users referred to mental hospitals in Paris (Katschnig & Cooper, 1991)). As a result, alternative crisis management has been successfully developed in America and Europe since the 1970s in small non- hospital units employing radically new approaches (Mosher & Menn, 1977, 1989; Warner, 1985; Moltzen et al. 1986; Ciompi et al. 1992).
Beyond descriptive studies (Bengelsdorf & Alden, 1987; Creed et al. 1989, 1990; Stein & Test, 1978, 1985) the evaluation of crisis interventions has specifically examined their effectiveness in reducing hospitalization rates and duration (Hoult, 1986; Hoult & Reynolds, 1984; Hoult et al. 1984; Muijen et al. 1992) as well as cost efficiency (Winter et al. 1987; Goldberg, 1991; Goldstein & Horgan, 1988). Day- hospital treatment has been compared with inpatient admission (Creed et al. 1989, 1990), short-term with long-term hospitalization (Hirsh et al. 1979) and 24-hour community treatment with hospital care (Rappaport et al. 1987).
AFTER-CARE
Further studies are needed to assess the effectiveness, acceptability, accessibility (Merson et al. 1992) and other possible advantages of alternative interventions vs. short and medium term hospitalization, with particular attention to institutionalization, relapses and chronicity (Drake & Sederer, 1986).
In this regard, the evaluation of acute case treatments has only rarely been supplemented by follow-up studies (Gognalons-Nicolet & Andreoli, 1991) which take into account the further therapeutic and rehabilitation treatments required. Decker & Stubblebine (1972), Levinson et al. (1992) and Reynolds et al. (1990) have shown the positive impact of crisis intervention approaches and community treatments on the course of the original condition, and Hoult (1986) has investigated the long term social integration of patients, a prerequisite to verifying the original, adaptational opportunities of crisis (Finch et al. 1991).
In fact, to the extent these therapeutic interventions are short-term and unprepared to deal with possible failures, they tend to have recourse to increasingly "harder" institutions, leading finally to the mental hospital. Several studies have described their obsolescence or limitations (Birger et al. 1974; Fisher et al. 1990; Scherl & Schmerz, 1989). Moreover, these models are generally not integrated with prevention and rehabilitation resources, nor with existing facilities; hence the lack of often necessary post-crisis support. It is well known that this lack of continuity of care has a negative impact, primarily on the course of acute psychotic states, leading to relapses and chronicity (Bennett, 1978; Wing & Brown 1970; Ciompi, 1980). New forms can also be shaped by this kind of fragmented institutional circuit, such as "young adult chronic patients" (Bachrach, 1982; Karras & Otis, 1987; Surles & McGuirrin, 1987) or specifically in our case, "emergency room repeaters", which have been described and even classified by American authors (Groves, 1978).
In addition, the above mentioned W.H.O. study (Cooper, 1979) found that these services mainly treat chronic or recurring non-adaptation states (disorders) which were the result of the "revolving- door" system and a distorted policy of de-institutionalization conceived merely as de-hospitalization, without continuous care and support in the community. Paradoxically, these services contributed to increase (and not filter) admissions to psychiatric institutions. The persistence of the mental hospital as a catch-all for the human refuse of any operational model guarantees the possibility of utilizing inflexible and selective technical schemes, while at the same time revealing their fragility. THE NEXUS BETWEEN COMPREHENSIVE SERVICES AND DE-INSTITUTIONALIZATION: THE CASE OF TRIESTE
A comprehensive community service should be able to identify, make contact with and work out the conflictual network of relationships which constitute a crisis and the crucial experience the individual is facing. In our opinion, the intervention must take into account this complexity which is otherwise hidden, trivialized or stripped of meaning by the process of simplification that usually occurs whenever the working model is based on the centrality of the mental hospital.
Obviously, the problem is not only proposing a more profound reading of the crisis at the cognitive and interpretative levels, but also the need for an organizational model of the service which will encourage appropriate responses to complex situations as and when they emerge.
It follows that approaches based on limited or sectorial models are to be avoided in favor of multi- disciplinary interventions employing a wide range of responses to the existential and social needs arising during a crisis. To this end, services must be equipped not only with health services but welfare resources as well.
Solutions to alternative crisis management in the community have been carried out in specific de- institutionalization experiences along two simultaneous tracks: 1) phasing out the mental hospital; 2) developing comprehensive community services able to meet the needs of a defined catchment area (Bennett, 1985; Rotelli et al. 1986; Rotelli, 1988; WHO, 1983). In order for an effective and significant de- institutionalization to be complete, alternative treatments must aim at reducing and finally abolishing any form of hospitalization by developing an adequate continuity of care during and after the crisis.
The Italian reform law of 1978 stressed that "mental health care should, as a rule, be carried out by community facilities and centers outside of hospitals". But an improper implementation of the law has often privileged the setting up of so-called Diagnosis and Treatment Psychiatric Services (DTPS) in general hospitals (with 15 beds), conceived as units accepting acute psychiatric demand in an undifferentiated way (Ongaro Basaglia, 1989). They are seldom coordinated with the CMHC, which are, moreover, insufficient in terms of staff and working hours (Frisanco, 1989; Tansella & Williams, 1987; Tansella et al. 1987; Crepet, 1990).
On the contrary, the de-institutionalization which began in Trieste in 1971, has completely phased out the local mental hospital (with 1200 beds), reconverting it into a totally alternative network of community services operating full-time (Dell'Acqua & Cogliati Dezza, 1986; Rotelli et al. 1986; Bennett, 1985) and equipped to cope with crisis (Paul & Turner, 1976).
The CMHCs are expected to respond to the full range of psychiatric demand in their catchment area, including acute demand, which is therefore not confined to a specific service or separated from unitary prevention, treatment and rehabilitation practices. PURPOSE OF THE STUDY
The research analyzed the therapeutic responses to acute/severe psychiatric demand in Trieste, which is often accompanied by problems of social disorder and a serious risk of social exclusion and disintegration. Our purpose was to evaluate whether a comprehensive community service could cope with these cases and the effectiveness of its response, both in the short-term (after the crisis intervention) and the long-term (course and outcome; social and institutional route of the patients).
The study attempts to investigate the assumption that good results can be attained through a community care system based on the following principles: 1) accessibility of services (mobility, flexibility) and the ability to cope with all kinds of crisis; 2) continuity of care; 3) integrated and comprehensive response (social and medical); 4) avoiding hospitalization in favour of more flexible forms of hospitality during the crisis. These principles, considered as intermediate goals, were also assessed by the study.
METHODOLOGY
SUBJECTS
The study was carried out at the Barcola CMHC, one of seven operating in Trieste (see Tables 1 and 2). Out of the total number of new users contacted in a situation of psychiatric crisis in 1985, subjects were selected according to at least three of the five following original criteria (Dell'Acqua & Mezzina, 1988): 1) severe acute symptomatology; 2) episodes of serious inter-personal breaks (or social withdrawal); 3) refusal of treatment but accepting contact; 4) total refusal of contact; 5) a situation of alarm in the family or social network.
These inclusion criteria defined a psycho-social acuity/severity of the disorder (and hence the service's commitment) and were not based solely on a clinical diagnosis. They were thus successful in identifying urgent (or emergency) situations which usually lead to recovery in psychiatric acute-care wards or entail forced admission to a mental hospital (because, prior to the Italian reform law of 1978, patients were deemed "a danger to themselves and others").
There were 136 new users out of a total of 427 users contacted during 1985. The incidence of service use was 0.302% total population, while the period-prevalence was 0.948%. Out of this group we found 39 crisis situations which met at least 3 of the abovementioned criteria.
PROCEDURES
The sample group underwent a 4-year follow-up. Information came from the operational data system of the Barcola CMHC and the other psychiatric services (DTPS, UPD) operating in the same territory. The data collected were studied by means of a specific original questionnaire and a final evaluation at the end of the study. This was accomplished by means of semi-structured interviews with the person and/or other key people. Relapses were identified using the same criteria as for the initial crisis. We considered the minimum time between totally overcoming a crisis episode and a possible relapse to be at least three months. In addition, any recurrence of the symptomatology considered as significant by the research group was taken into consideration.
RESULTS
SAMPLE TYPOLOGY AND PHENOMENOLOGY OF THE CRISIS
The sociodemographic make-up was as follows: 59% women; 50% over 55 years of age (26% over 65), 35.9% married. Most lived in a family (66.6%) and in good or sufficient housing conditions (66.6%). Income came from pensions (51.3%) or from the user's or family members' regular jobs; the majority had at least a junior high school education.
For a description of the phenomenology of the crisis see Table 3. The diagnoses were grouped on axis I of DSM-III. Eleven of 39 subjects were initially characterized by attempted suicide. Forty two percent of the sample suffered from schizophrenia, paranoid or other psychoses and 26% from affective disorders.
INTERVENTION IN THE INITIAL CRISIS: FEATURES AND OUTCOMES
Crisis intervention is described in Table 4. The users themselves or family members were the main sources of referral. All cases (38.5%) which first arrived at the DTPS were sent to the CMHC within 24 hours. The services provided during the crisis are summarized in Table 5. As to medication, major tranquilizers from a minimum dose-equivalent of 2 mg to a maximum of 10 mg of haloperidol daily were used, with or without minor tranquilizers from a minimum dose-equivalent of 10 mg. to a maximum of 90 mg diazepam in 24 hours; sedation (see maximum dosages described above) was used in three cases only.
Alarm was generally the first indicator to cease (64.1%) together with partial or total refusal of care in most cases. It was not necessary to apply even one CHT. All the criteria were no longer evident (overcoming the crisis) within 7 days in 41% of cases and within 3 months in a further 28.2%. Psychiatric symptomatology was evident in only 4 cases after 3 months.
Day-night hospitality in the CMHC was used in 18 cases (46.1%) during the first crisis episode, with an average duration of 7.9 days. There were no admissions into the DTPS. Two subjects were subsequently hospitalized in the UPD, one on their own initiative and one at the request of family members. Five subjects were admitted to medical or geriatric wards due to concomitant organic diseases; of these, two died.
FOLLOW-UP
Excluding the two deceased subjects, 37 cases actually entered the follow-up after the initial crisis intervention (see Table 6). For the overall duration of the therapeutic relationship with the service refer to Figure 1.
It should be noted that a single contact with the service was sufficient to settle the crisis in four cases, with no relapse. The cases in question were depressive and adjustment reactions to relational problems or cases of organic interest which were referred for general medical care. Only 9 subjects (23.0%) received short-stay complete hospitality treatment (less than 6.9 days) during relapses (see Table 7). The moderate use of hospitality in the CMHC is summarized in Table 7.
When the total number of observations is considered (39 "first crisis" plus 34 subsequent episodes, critical and non, for a total of 73 observations), the results indicate no statistically significant correlation between "crisis" (severity) and "admission-response" in the CMHC (p = not significant).
According to the results, 10 subjects had had single contacts with the DTPS without admission. Of these, three had been admitted to the UPD and one subject was admitted there twice. As to possible trans-institutionalization experiences, we underline that no crimes occurred and no one was interned in either prison or a forensic mental hospital. Likewise, no CHT was applied during the follow-up.
The longitudinal study showed that 29 cases had no "crisis" relapse, though eight of these showed a significant recurrence of acute symptomatology without the other psychosocial criteria of "crisis" (one case more than once). The remaining eight users had "crisis" relapses (21.6%); of these, two more than once. Of the 16 users experiencing either a crisis or a simple recurrence, 11 (68.7%) were diagnosed as psychotic, four as suffering from affective disorders and one as alcohol dependent with an affective disorder.
The trend of total time required to overcome the crisis (i.e. when none of the initial criteria was any longer evident) decreased considerably in all these situations; while results show that the first crisis lasted 63.4 days on average, subsequently the crisis lasted 55.8 days in the second episode, 49.4 days in the third, 11 days in the following episodes (see Figure 2).
By crossing types of symptomatologic courses with diagnoses, we drew up the outline described in Figure 2, which points out the prevalence of favorable courses. There were no suicides. Of the 11 subjects who attempted suicide during the first crisis, none made a second attempt during the follow- up. Of the remaining subjects, only one attempted suicide in the follow-up. Another seven patients (four over 65) died during the follow-up, all due to serious concomitant organic diseases (see III axis of the DSM-III). Maintenance anti-psychotic therapy with depot major tranquilizers was used in 9 cases: five subjects began after the first crisis, another four later on. In no case was treatment continuous for the whole follow-up period and in only three cases was it greater than half that period (standard monthly dosage per person: 50 mg of haloperidol decanoate and 25 mg of fluphenazine decanoate).
FINAL EVALUATION
For the final evaluation see Table 6. We emphasize that only five of the 10 subjects (seven men, three women) still in contact with the service presented psychiatric disorders already underway (three diagnosed with schizophrenic psychosis, two with bipolar affective disorder) and needed treatment; the remaining five cases were in contact with the service for rehabilitation or socialization (activities in the various workshops, jobs or vocational training in the co-ops, use of the CMHC for relationship-building).
We wished to further evaluate whether continuous and long-term relationships with the service (over 3 years) had led to a high utilization according to the evaluation proposed by Lavik (1983) relative to services used (yearly score greater than 100). The results show that this definition applied to one male subject (score of 162 for 1988).
Twenty-eight of the 30 patients considered in the final evaluation lived with their families or had remained in their own living environment, two (over 65) were admitted to nursing homes. There was only one change in civil status due to a separation and no worsening of family conflict levels, which instead improved in two cases. Working conditions improved in one case (an unemployed man who now works in a co-op) and worsened in two (dismissal, job-level downgrading). The adaptation levels (social relationships--work performance--use of leisure time) which were evaluated globally on axis V of the DSM-III worsened by one level in one case only (bipolar affective disorder), improved in four cases (two atypical psychoses and two affective disorders) and remained substantially unchanged for the remaining cases.
ASSUMED PROGNOSTIC VARIABLES
We divided the 37 subjects who actually entered the follow-up into two groups: the first made up of 21 patients with previous psychiatric contacts and the second of 16 patients without any previous contact ("first ever"). The final evaluation results show that no one in the "first ever" group presented any psychiatric disorder, while 18.5% of those with previous psychiatric contacts needed treatment.
We further divided the 37 individuals into a "community response" group, or those who had been followed only by the CMHC (27 subjects), and a "mixed institutional course" group composed of those who had been hospitalized elsewhere or had had different psychiatric contacts (10 subjects). The results showed that, although the two groups overlapped for diagnostic distribution, 33.3% in the first group (9 subjects) as compared to 70% (seven subjects) in the second relapsed, thus marking a statistically significant difference (p = 0.05).
DISCUSSION
The international debate on crisis intervention and acute services seems to be concentrated on the search for appropriate service features, such as efficiency, rapid response, working hours, inter- dependence with health and social agencies, triage systems beginning with case assessment (Turner & Turner, 1991). It also tends to separate emergency intervention (contact, triage, decision-making procedures) from the actual treatment of acute cases, often considering severe cases beyond the operational domain of crisis intervention. The offer of service is considered to be balanced by limitation systems as far as the access of undifferentiated demand is concerned. There is, in any case, "a considerable degree of uncertainty as to which organizational structures are the most appropriate for each type of demand for help" (Katschnig & Cooper, 1991).
Specialized services tend to be selective and the absence of stigma can permit them to arrive "before" illness conditions have been established. However, since severe cases are generally excluded from their range of action, these return as an overall problem for the psychiatric services, usually leading to the mental hospital once they have become clearly evident.
If CMHCs are conceived as simple out-patient clinics that await the patient and rigidify the protocol of intervention, thereby accepting their peripheral position in regard to hospital units, they will remain ineffective in coping with acute crisis and inevitably delegate a recourse to the traumatic mechanism of compulsory treatment or, at the very least, to admission in acute units, like in Italy (Saraceno & Tognoni, 1989).
In order to prevent these distortions, comprehensive services must control the activity of health and social services in terms of demand patterns, thereby becoming strategic filters in a given catchment area (Paul & Turner, 1976).
At the same time, they must be equipped with adequate resources and alternatives to the various forms of psychiatric hospitalization (Gallio, 1978), while working towards a fully implemented de- institutionalization that recycles resources and provides adequate after-care.
In our study, the typology of acute/severe demand arriving at the service indicates that users are sufficiently socially integrated. Community response seems to meet illness conditions in a more timely way, so users are not yet marked by serious social withdrawal or social drift (Eaton, 1980).
When the diagnostic distribution is compared to that of other Italian studies on Diagnosis and Treatment Psychiatric Services (Asioli et al. 1986; De Girolamo et al. 1988), our group is seen to be representative of acute patients. Even in cases with serious symptomatology, CMHCs accepted all crisis demand arriving at the service (no direct selection), whereas the same demand would most likely have resulted in a DTPS admission in areas without a 24-hour comprehensive CMHC.
The service is disposed to deal with any given crisis without selection based on either pre- determined therapeutic models, or a criterion of severity or typology with consequent referral to hospital facilities.
Even if two or three users first contacted the service after experiencing other psychiatric responses and despite the "urgency" connected with the demand typology, the great majority of our sample were "direct" arrivals at the CMHC, confirming the absence of institutional preferential or separate patterns of care for acute patients. Cases in the study which initially came to the psychiatric first-aid station, improperly called DTPS, were passed on to the CMHC within 24 hours (with no admissions to the DTPS).
It should be noted that the DTPS is an agency managed directly by the community services and does not treat crisis cases without requesting CMHC intervention; it does not usually hospitalize patients. The PUD and private clinics exclude a direct admission of acute demand. Thus no patients bypassed the CMHC; and the sample can be considered representative not only of who arrived at the service, but of whatever can be defined as an acute/serious case within the catchment area (accessibility).
If we examine the intervention procedures at the initial crisis, it is our belief the data concerning the contact show the high flexibility of the service and its ability to cope with crisis difficulties. Different kinds and places of contact are useful in reconstructing a subject's life history and in situating the crisis within a series of relationships which, in turn, render it comprehensible. As part of the strategy to "dismantle and de-construct" alarm mechanisms, referrals to emergency agencies such as Red Cross and police were avoided. Conversely, the availability of mental health professionals and the extremely diverse and informal approach modalities elsewhere described (Dell'Acqua & Mezzina, 1988, 1988a) also help to explain how initial resistance to the contact could be overcome, thereby totally avoiding CHTs in our sample group. All cases which presented an initial "hard" refusal of therapeutic contact were accepted without any form of referral or abandonment. The user's declared opposition was generally overcome after the initial impact, confirming that the use of CHTs depends more on service features such as accessibility and mobility than on urgency or specific diagnosis, and can be traced to the breakdown of social support networks (Katschnig & Cooper, 1991). The fact that conditions of alarm were overcome early seems to show that contact modalities were also effective in reassuring all those involved.
Results show that the service was able to initiate other appropriate welfare and health responses such as admission for general medical disorders without automatically "passing the buck", while at the same time providing continuity of care for all those situations requiring long-term therapeutic interventions which were integrated step by step with rehabilitation. In these cases, patients were encouraged to maintain contact after the crisis (Mosher & Burti, 1989). The wide range of resources and services adopted reflect the service's flexibility and comprehensive care capability, and permit it to plan and contract personalized therapeutic programs once the basis for a relationship with the patient has been established. The features of each therapeutic program is based on individual history, needs and requirement, thus enabling the service both to obtain and keep consent to treatment, and actively involving the user and his social network in various plans of support (Mosher & Burti, 1989).
There were absolutely no "rop-outs" in the sample. The follow-ups avoided CHTs and favored a continuity of care which contributed to maintaining subjects in their social environment, thereby avoiding de-socialization and abandonment, and the risk of institutional or trans-institutional solutions (jail, forensic hospitals) even though a special prison crisis intervention team had been organized in case of need (Reali & Shapland, 1986; Mezzina, 1993). All interventions aimed at avoiding psychiatric hospitalization, the alternative being the 24-hour hospitality in the CMHC. The hospitality/admission response in the CMHC is applied on the basis of "case by case" evaluations which take into account diverse criteria (e.g. social support network, type of therapeutic relationship, levels of individual accountability, acceptability or harmfulness of the contact with the environment, etc.), and not merely the symptomatology or factors of severity and risk.
During the follow-up, episodes requiring hospitality were infrequent and time-limited. In fact, when the service takes on full responsibility for a case, it overcomes in a very concrete way the opposition between in-patient/out-patient treatment typical of the medical model, given that a specific place of care is no longer implied. That place can be either the CMHC, or other agencies and services, though most often it is the user's own environment. The CMHC's 24-hour hospitality does not sever ties with this environment (family contacts, time away from the centre alone or accompanied, taking care of specific personal needs). If the user should break the agreement by leaving the center, every effort is made to re-establish contact by seeking him out and listening to his requests and claims (re-contracting). In any case, hospitality is only one phase in the overall response to each case, and is preceded and followed by other modalities.
Short-term outcomes were positive as clearly shown by the rapid resolution of first crises. As regards those cases without subsequent crises, we can suppose that the initial intervention was able to give the correct therapeutic input to the user and his microsocial environment in many situations, either helping him to overcome the specific psycho-social (mainly relational) event or situation which triggered the crisis, or discovering resources in the environment or in other welfare and health services. In the case of relapses, the shorter crisis duration -- the importance of which has been correctly linked to the maintenance of social roles (Mosher & Burti, 1989) -- clearly show the attenuation of the psycho-social severity of the crisis-event and the modification of psycho-pathological expression when a relationship with the service had already been established.
Also the long-term course and outcome typology was, on the whole, satisfactory. We emphasize not only that there were no suicides, but that the attempted suicides had not repeated (even though the risk of "emergency repeaters" pointed out in the literature was hereby confirmed -- Peterson & Bongar, 1990). The burden placed on the service by cases presenting more serious problems and requiring long- term support never led to long-term hospitalizations. The number of situations requiring "high- utilization" of community services remained extremely low.
In this regard, crosstabulations tend to indicate (though not enough for statistical significance) that subjects living with their families of origin needed more, longer and more demanding interventions due to the longer persistence of psychiatric problems; the opposite holds true for those subjects who lived in a conjugal family. A crosstabulation on gender tends to show women took less time to overcome the crisis and that their therapeutic relationship with the service lasted less as compared to men. All these data, together with those regarding the maintenance of good adaptation and social integration levels (derived from documentary evidence on changes in marital status, work, family environment) suggest that there exists an effective secondary and tertiary prevention, as already shown by a multicenter study (in which our service took part) on the long-term psycho-social outcome of schizophrenic psychosis (Kemali et al. 1989).
In addition to confirming important prognostic variables in a negative sense, e.g. the presence of psychiatric precedents (particularly hospitalization, as pointed out by the IPSS of the W.H.O.: Jablensky, 1981), the follow-up shows that there were better outcomes for those patients who had established a relationship of trust with the service and therefore had had therapeutic responses only from it, as compared to those who had moved back and forth between different institutional agencies, either on their own or due to family pressure, or for other reasons. Even though these data are difficult to interpret, they may provide a basis for further prognostic variables.
CONCLUSION
In our experience in Trieste, we chose not to create separate crisis services, but to integrate crisis intervention as part of a comprehensive community service. In our opinion, the organization and philosophy of a CMHC, which ought to provide a unified prevention, treatment and rehabilitation service for all potential cases in its catchment area, should be based on the following: 1) non-selection of demand (i.e. not based on inflexible therapeutic models or severity thresholds); 2) non- hospitalization; 3) a high degree of flexibility and mobility; 4) the involvement of multiple resources (such as a wide range of welfare provisions) in the therapeutic and support programs (comprehensiveness). In addition, integration with the DTPS enables it to cover the wide range of urgent cases that usually arrive in hospital emergency wards.
The study shows that this choice promotes a "soft" and direct accessibility for the demand, thereby changing the previous institutional patterns (police, Red Cross, general hospital, etc.) that contribute to the "montage" of crisis, and facilitating intervention by related community social and health services. As a rule, crisis treatment modalities in the CMHC are radically alternative to any kind of psychiatric hospitalization. The extremely widespread, informal and flexible approaches in the intervention explain how it was possible to overcome difficult impacts and avoid CHTs. Continuity of care has favored positive courses and outcomes, and avoided destructive social routes for the users (social drift, institutionalization, abandonment). Instead of following the most common strategy of crisis intervention which aims at resolving conflict within the personal context (familial or micro-social) and attempts to arrive at a rapid normalization of the individual, crisis response in our case is more inclined to connecting and placing the user in contact with a system of relations and the human and material resources present in a community service.
The user must be enabled to pass through the crisis with his historical and existential continuity intact. In order to do this, the user's ties with his environment must be maintained, the links between the crisis and his life history must be identified, and significant existing relationships must be reconstructed and redefined while new ones are formed. The crisis can thus lose its characteristics of rupture and dissolution of the existential continuity, and acquire a dynamic value. The impact of the service, likewise an historical event, is crucial in determining the nature of that outcome, either expropriating, underlining and confirming the rupture, or endeavoring to research and respond.
Added material
Roberto Mezzina, psychiatrist, is currently responsible for the community mental health center of Barcola, Trieste, Italy.
Daniela Vidoni, psychiatrist, was formerly a researcher in the same center and now is at SERT (Drug Addicition Service) in Trieste.
Correspondence to: Roberto Mezzina, Centro di Salute Mentale, viale Miramare 111, 34100 Trieste, Italy.
Table 1 Features of Barcola CMHC (1985)
No.
Catchment Area 45,000 inhab.
Square Km 10.5
Number of Beds 8
Group-homes 4 (22 guests)
Staff:
Psychiatrists 3 Social Workers 2
Psychiatric nurses 26
Table 2 Services provided by Barcola CMHC (1985)
No.
Night-hospital (days) 2.346
Day-hospital (days) 32.946
Out-patients visits 6.606
Home visits 1.357
Patients with subsidies 166
Patients with vocational work-grant 37
Co-operation with Welfare and Health Services 299
Welfare services directly provided by CMHC 521
Table 3 Phenomenology of the crisis
Percentage
1. PREVIOUS PSYCHIATRIC CONTACTS
1.1. Present 58.9
1.2. First contact ever 41.1
2. CRISIS CRITERIA MET BY SAMPLE
2.1. Severe acute psychiatric symptomatology > 90
2.2. Break in family environment 2.3. Alarm in environment
2.4. Initial refusal of treatment 15.4
2.5. Total refusal of contact 10.3
3. PRESENCE OF LIFE EVENTS
3.1. Moderate or serious life events identified in last year 39
(levels 4/5 on IV axis of DSM III)
4. FAMILY SITUATION
4.1. Open conflicts 43.4
4.2. Communication problems 15.4
4.3. No evident problem 23.1
Table 4 Crisis intervention
Percentage
1. THE CONTACT
1.1. a) Demand
1.1.1. Directed to service itself 61.5
Of these:
Upon indication of hospital health professionals or general practitioners 26.5
Family member or friends 20.5
Others 14.7
1.1.2. First arrived at DTPS 38.5
1.2. b) Place
1.2.1. Patient's home 33.3 1.2.2. CMHC 25.6
1.2.3. DTPS 23.1
1.2.4. Other 18.0
2. EMERGENCY AGENCY INTERVENTION(FN*)
2.1. Red Cross 23.1
2.2. Police 12.8
FOOTNOTE
* Called by service in one case only.
Table 5 Services supplied by CMHC during the crisi
Percentage
1. Individual support psychotherapies or family counselling 100
2. Involvement of social network 100
3. Specific re-socialization treatment 28.6
e.g. 3.1 group therapies
3.2 art-therapies
3.3 self-help groups
3.4 occupational therapies in CMHC
3.5 support of non-professional caregivers and volunteers
4. Legal advocacy 10.25
5. Intensive job support or new employment 5.12
6. Self-care management and housing support 5.12
7. Co-operation with other welfare and health services 33.3 e.g. 7.1 request of pension, elderly home support
7.2 check of physical health
8. Medication 100
Table 7 Admissions to CMHC
Percentage
Patients admitted to CMHC 18 of 39 at first crisis 46.15
9 of 37 in 4 years of follow-up 24.37
49 admissions
Admission to CMHC relapse rate ------= 2.2 for first crisis and follow-up
22 cases admitted
Duration of complete hospitality in CMHC < 30 days for 21 patients
31-60 days for 1 patient
> 60 days for 0 patients
Average duration of complete hospitality 7.9 days at first crisis
6.9 days for relapses
Follow-up: synoptic table
Figure 1. Duration of therapeutic relationship with CMHC
Figure 2. Type of course
ACKNOWLEDGEMENTS This research can be considered as a pilot-study for the elaboration of a set of tools for crisis evaluation (specifically to measure crisis impact and burden on services) which have been developed together by Centro Studi e Ricerche Salute Mentale -- Regione Friuli-Venezia Giulia -- W.H.O. Collaborating Centre, and Istituto Superiore di Sanità -- Roma. These tools are now available.
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WBN: 9510502694001