Social Systems Intervention and Crisis Resolution. Part 1: Assessment Christopher Bridgett & Paul Polak

Bridgett & Polak Advances in Psychiatric Treatment (2003), vol. 9, 424–431

Social systems intervention and crisis resolution. Part 1: Assessment Christopher Bridgett & Paul Polak

Abstract Home treatment as an alternative to acute adult in-patient care is part of the National Health Service Plan for mental health services in the UK. As a form of crisis intervention, it benefits from an understanding of, and ways of working with, the social systems relevant to the patient in crisis. This article reviews relevant terminology and background theory, and considers the social factors associated with psychiatric admission.

This is the first of a two-part article. Part 2 (Bridgett & Polak, interest to generic community mental health teams 2003, this issue) gives an account of social systems interventions and considers also the application of the approach in achieving (Department of Health, 2002b), specialist assertive early discharge from in-patient care. outreach teams (Department of Health, 2001a) and early-intervention teams (Department of Health, 2001c) and to approved social workers performing The National Health Service (NHS) Plan (Depart- assessments under the Mental Health Act 1983 ment of Health, 2000) set out an intention to establish (Dunn, 2001). 335 crisis resolution and home treatment teams in The theoretical background (Caplan, 1964, 1974; England by 2004, with the expectation that bed usage Polak, 1967, 1970) and practical procedures (Fish, in acute adult general psychiatry could be further 1971; Polak, 1971a, 1972) brought together here were reduced (Joy et al, 2001). The initiative also aimed to first explored and established 30 and more years make generally available a more acceptable and ago. One of the earliest mobile psychiatric emergency appropriate model of care, including ‘interventions services was set up in Amsterdam 70 years ago, with aimed at maintaining and improving social the aim of preventing hospitalisation (Querido, networks’ (Department of Health, 2001b: p. 16). 1968). As community psychiatry has developed, the The work of these teams is usually characterised relevance of social context in general (Cohen, 2000), as diverting care away from admission beds and crisis intervention in particular (Hoult, 1986; (Brimblecombe, 2001). However, enabling early Rosen, 1997; Minghella et al, 1998; Joy et al, 2001), in discharge, when admission has not been avoided, providing acute psychiatric care has remained can also be part of their routine remit. crucial. Certainly, clinical experience in setting up This article emerged from the experience of one and running current crisis resolution and home crisis resolution team receiving in-service training treatment teams endorses the continuing relevance in social systems intervention and crisis resolution. of social systems intervention when resolving crises The team asked for something to refer to, in the way in acute mental health care. of a practical ‘how to do it’ guide, supplementing theoretical instruction and complementing other- wise invaluable on-the-job training. As in-patient Terminology and theory wards review their working practices and align themselves with crisis resolution teams (Department ‘Crisis’ implies here a failure in adequate coping of Health, 2002a), this guide also serves as an (Minghella et al, 1998) associated with an acute introduction for ward staff to the relevance of social episode of mental illness or distress. When the context when providing in-patient care. Further- individual’s resources and the existing support from more, it is anticipated that this overview will be of others have been exhausted and, conventionally,

Christopher Bridgett is the consultant psychiatrist with the South Kensington and Chelsea Crisis Resolution Team, London, and honorary clinical senior lecturer at Imperial College School of Medicine, London (Central and North West London NHS Trust, South Kensington and Chelsea Mental Health Centre, 1 Nightingale Place, London SW10 9NG, UK. E-mail: [email protected]). Paul Polak is the president and founder of International Development Enterprises, Lakewood, Colorado, USA, and was the executive director and founder of Southwest Denver Community Mental Health Services, Denver, Colorado.

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Box 1 Crises Box 3 Social systems Non-illness, brief reactions to stress Sets of interactive relationships Feature adaptive or maladaptive coping Vary in size and formality Involve individuals and social systems Sensitive to external stresses Increase accessibility for help Liable to internal conflicts Can occur in connected series Individuals can relate to several systems admission to hospital is indicated, the term ‘referral These are embedded in less-intimate, community crisis’ is appropriate. Caplan (1964) more generally relationships with a general social group cohesive- defined crises as brief, non-illness responses to ness that is referred to as ‘social capital’ (Kawachi stress (Box 1). Thus, a crisis is not a clinical disorder, & Berkman, 2001). Although social support for the although the one can cause the other. Equally, stress individual derives from belonging to a social is not a crisis, although it might provoke one. An network, networks do not guarantee the availability emergency is more than a crisis and it requires a of support (Dickinson et al, 2002). The cohesiveness different type of response. of an overall social group can sometimes work ‘Crisis intervention’ (Box 2) is characterised by against a stigmatised individual (McKenzie et al, rapid response and intense, short-time work, in the 2002), when for example members of a group share ‘here and now’ (Waldron, 1984). It usually involves a strong negative attitude towards an individual’s working with social networks. Intervention should behaviour. be aimed at detecting maladaptive responses – Understanding a mental health crisis in terms of denial of difficulty, failure to express feeling, avoid- social system breakdown (Polak, 1972) leads to ance of help – in order that help can be provided ‘social systems intervention’ as a technique for and healthy coping facilitated. Most such interven- achieving crisis resolution, and this can provide an tion is not the province of psychiatry (Rosen, 1997). alternative to admission to hospital. As shown in Several crises might have been involved in the vignette 1, a particular stressful event such as process leading to a referral for possible in-patient bereavement might equally cause a crisis for a social care: admission itself can represent a social systems system as it does for an individual within the crisis (Polak, 1967). The referral crisis that precipi- system.1 tates contact with a crisis resolution team may be the end result of a series of unresolved crises in more Vignette 1 than one social system. For intervention to be A young man becomes profoundly depressed after appropriate it is important to be able to identify and the death of his father. When his mother, despite his describe each crisis clearly. frame of mind, expects him to act as host for social The predicament of the individual can thus be gatherings, major conflict emerges, with further understood within a broad social network. This deterioration in his mental state. The crisis of loss and grief that he is experiencing is network has been described as a series of over- mirrored by a separation crisis for the family – his lapping social systems (Polak, 1971a, 1972): sets of widowed mother and his sister. There is now a risk interactive human relationships that vary in size, of regression of the social system, with labelling, formality, function and permanence (Box 3). Like scapegoating and extrusion: admission to hospital individuals, social systems are both sensitive to may result. Furthermore, the healthy process of external stress and liable to internal conflict. They grieving in individual family members may become can cope adaptively or maladaptively. An individual inhibited. often relates to several social systems at any one A simple social systems intervention – meeting time. Some are relatively intimate and egocentric. with all concerned and facilitating discussion – enables the reconstitution of a supportive social framework, within which the son’s incapacitating depression is successfully treated without admission to hospital, Box 2 Crisis intervention and important roles and functions within the family Rapid response offered in situ, rather than (such as breadwinner and host) are successfully reorganised and reallocated. elsewhere Intense, ‘here and now’, short-term Usually not by mental health services 1. The illustrative case studies are based on real cases, Facilitates ‘healthy coping’ but details have been omitted or changed to ensure that Usually involves social networks there is no breach of confidentiality.

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Crisis theory (Rosen, 1997), which was partly that bring the patient there (Polak, 1971b). The derived from general system theory (Von Bertalanffy, process of admission seals the avoidance and denial 1968), proposes that a crisis represents both a risk of social systems problems, with medicalisation of regression and failure and an opportunity for emphasised on admission by the mandatory constructive growth and adaptation. At the time of physical examination, often with routine laboratory crisis there can be an increased accessibility to and radiological investigations. After a day or so, offered help, and small interventions can relatively any awareness of the social reasons behind the quickly produce large changes in coping. Crisis admission can be lost, especially when those theory thus indicates that detection and intervention involved in the admission decision are off duty, or are best sooner rather than later, and in situ rather are not involved in ongoing in-patient care. Hence, than elsewhere. there is a powerful and stigmatising tendency for ‘Complexity science’ (Plsek & Greenhalgh, 2001), the need for in-patient care to be subsequently re- which echoes aspects of general system theory, also framed in terms of the individual and not in terms provides a framework for understanding how of his or her social circumstances (Polak, 1970, individuals behave in social systems. Social systems 1971b). This phenomenon, first described 30 years are examples of complex adaptive systems. In such ago, seems have been exaggerated by the intervening systems, events occur in ways that are not totally ascendance of biological psychiatry (Cohen, 2000; predictable, but are nevertheless interconnected: one Double, 2002). Additional contributory factors agent’s action changes the context for other agents. include a recent emphasis on developing resources This framework is applicable to the majority of outside the hospital, a consequent general neglect clinical situations: ‘few if any human illnesses can of the process of psychiatric in-patient care, and an be said to have a single “cause” or “cure”’ (Wilson increasingly custodial response to the perceived risk & Holt, 2001). of violence (Wall et al, 1999). In hospital, the patient’s mental state, diagnosis, need for medication and risk management become the overriding concerns. Social factors and admission Subsequently, when discharge from in-patient care seems feasible from the medical point of view, delays Despite the common assumption that psychiatric and difficulties can occur, as relevant but so far admission to hospital can be regarded as synony- neglected social issues come back into focus. mous with an episode of ‘real’ mental illness, it is It was previously estimated that the average acute evident that admission of a patient in acute mental psychiatric admission addressed only one-third distress can be as much a social as a medical (largely related to the individual) of the pertinent necessity (Polak, 1967; Morrice, 1968; Polak & Jones, issues creating the need for hospitalisation. Two- 1973; Tyrer, 1993). Such an admission is usually thirds (largely related to social circumstances) necessary to deal with a crisis in coping after one remain to cause future difficulties on discharge or more significant life events – the resources (Polak, 1967; Morrice, 1968). Discharge from for dealing with the situation otherwise seem traditional in-patient care may be deemed feasible exhausted. However, a common potential side-effect because the individual is now more able to cope, or of the admission is to translate what should at least because circumstances outside hospital are now partly be understood as a social necessity into a more favourable to coping. However, if the social medical problem requiring medical treatment: after circumstances that caused the admission in the first all, the social context is now the hospital (Box 4). place have remained throughout the admission, they It has been argued that the social environment of can be reactivated on discharge. While in hospital, the psychiatric ward has little or no relevance to the the individual’s coping resources may have become disturbances in social context in the real-life setting adequate, even though illness behaviour may have been reinforced by the ward environment. But on discharge, the natural environment within relevant Box 4 Side-effects of in-patient admission social systems may prove relatively hostile, and unresolved conflicts and communication problems Neglect of usual social circumstances (Polak, 1971a) may remain, once more testing the Emphasis on the medical model individual’s coping ability. Stigmatising exposure to an institutional social context Vignette 2 Disengagement with community mental health A woman is admitted to hospital after a serious teams overdose precipitated by her 30-year-old daughter’s Delayed discharge going on holiday. Her severe depressive illness Readmission apparently reflects her inability to negotiate a healthy process of emancipation for her daughter. The

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admission removes the mother from the conflict It is important to note that, although the process of situation, and with the passage of time and treatment labelling, scapegoating and extrusion applies to with antidepressants, her depression remits. some cases of admission to hospital, it is by no means The cause of the illness has not been resolved by a central feature in all cases. A crisis resolution team hospital admission. Although the mother is discharged needs to keep a watchful eye out for the phenomenon with an improved mental state, if the failure in mother/ and aim to work on reversing the process when it is daughter emancipation is not addressed, the risk exists of recurrent depression. Moreover, what might now clear from initial assessment that it is a factor. What may take weeks of discussion may have been achieved is needed by way of intervention will vary with the in a few days of appropriate intervention in the circumstances. situation that led to the admission. Once a crisis resolution team is established, all subsequent requests for admission to in-patient care Labelling, scapegoating and extrusion (see vignette should be filtered through the team. This important 1) are social processes that can lead to psychiatric gatekeeping role (Protheroe & Carroll, 2001) should admission (Polak, 1972). When a social system is identify among patients who do require in-patient affected by a significant life event it enters a period care the many who might benefit from early of disequilibrium. A vulnerable person within such discharge with help from the crisis resolution team a system may take the brunt of the disturbance and (see Part 2: Bridgett & Polak, 2003, this issue). The be labelled by the system as a patient. The patient relevant social factors noted at the time of admission can then become a scapegoat. The system may will include some that can be addressed immediately establish a new equilibrium, albeit maladaptively, and others that should await future action – at by extrusion: admission of the patient to hospital. discharge or later. Hence the benefits of integrating the work of the crisis resolution team with that of the Vignette 3 ward (Department of Health, 2002a; Smyth, 2003). A teenage girl is admitted to the ward for the treatment of a severe depressive illness. Subsequent assessment reveals that her father has died suddenly and that the Crisis assessment and practical patient is expressing grief for the whole family. This is a response to the mother’s lead in never expressing problem-solving sadness at their loss. The grief of the patient is intoler- able for her family. Admission to hospital removes The crisis resolution team is sometimes styled a the very painful reminder of loss for the family. ‘ward on wheels’, since it travels to the patient outside of the hospital. This is misleading if it means Chronic disturbed behaviour may be accommodated that the same type of care is applied outside hospital within a social system until an event upsets the as on the ward. If this is all that is achieved, there is equilibrium of the system. Then the behaviour may a good chance that the quality of care will improve, become intolerable, with the system labelling it as but problems in the patients’ social setting might deviant: the person is now seen as a patient in need continue to be ignored almost as much as they are of professional help. The system extrudes the in routine hospital treatment. scapegoated individual into hospital, closing ranks Expertise on the ward in understanding the indi- behind as this happens. The process is confirmed vidual in terms of mental and physical status needs by the fact that the assessing professionals have to be expanded off the ward to achieve a similar deemed in-patient care to be appropriate. expertise in assessing and dealing with relevant Vignette 4 social difficulties (Campbell & Szmukler, 1993). A teenage girl takes an overdose, her distress high- Those that are easiest to understand and cope with lighting her mother’s chronically disturbed behaviour. are the practical matters of day-to-day life (Box 5). The mother is a long-standing drug user, and because All of these are immediately (and conveniently) of her habit has been unable to attend to her daugh- ‘solved’, almost without thought, by admission to ter’s needs. The extended family has previously coped by substituting the grandmother’s care for the daughter. When the grandmother recently died, the Box 5 Practical social problems for a crisis girl went to live with her uncle, who rapidly found the situation intolerable. Following the girl’s overdose the resolution team uncle seeks professional help for the mother (his sister): her intoxicated behaviour becomes labelled as illness, Shortage of money and in-patient treatment is arranged. The crisis Inadequate shelter resolution team then agrees to enable early discharge Risk of accident from the ward, meeting with the family and providing Danger of exploitation continuing home-based treatment. The uncle re- Neglect of self-care and diet negotiates his niece’s care within the extended family.

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Box 6 Crisis resolution team tasks transferred Box 8 Commonly involved social systems from the ward Family Medical assessment of physical and mental state Friends Prescription and dispensing of medication Neighbours Risk management Colleagues Provision of ongoing support and supervision Carers Communication and liaison

The ‘story so far’ can be profoundly enriched by hospital. The new member of a crisis resolution team asking for more information, not so much from the quickly grasps the need to recognise the opportuni- patient, but from significant others. Who else can ties to act in a common-sense and practical way to say more about what is already known? How can obviate admission. Having the wherewithal to take they be contacted? How does their point of view someone home from the accident and emergency raise further issues to discuss with the patient? department via the supermarket to buy a bag of With which of the patient’s social systems can the groceries and recharge an electricity key is clearly referral crisis be most closely identified? (Box 8) crucial. The duty doctor or the bed manager can only (Polak, 1967; Fish, 1971; Polak & Kirby, 1976; Polak offer a bed. et al, 1977). Thus, within a couple of weeks of becoming The origin of the related social systems crisis needs operational the new crisis resolution team becomes to be determined (Box 9). Is the ‘illness’ more a cause familiar with how routine ward procedures (Box 6) or an effect of the crisis? What aspects of which can be transferred to people’s homes, and how often social systems can be identified as strengths to be this is welcomed by both patients and carers. The harnessed in formulating a care plan? solving of practical problems and even dealing with Others – key informants – therefore need to be issues of communication and internal politics involved in further assessment of the crisis. An initial surrounding the introduction of a new service hypothesis should then be formed concerning the quickly seem manageable. nature of the crisis, to give a focus to the assessment. This can be especially useful when there seem to be many issues involved. The hypothesis should link Social systems assessment: with the initial goals of crisis resolution team preliminaries involvement. Subsequent ‘drift’ in the work of the team can then be avoided. The difference between a traditional ward approach The enquiries, often by telephone, can be particu- and that of a crisis resolution team using a social larly useful when they are made sooner rather than systems approach becomes evident when cases are later – immediately after the initial referral has been presented between colleagues. On the ward, admis- taken and before any lengthy interview with the sions are usually presented with an emphasis on patient concerned. mental state, differential diagnosis, safety and Experience shows just three telephone calls can medication. The focus is on the patient concerned establish which social systems are involved, which and the account he or she has given, and on infor- social systems crisis it is practical to tackle first, and mation provided by the referrer – perhaps a duty who to invite to the first social system meeting. doctor or duty community mental health team It must be only in exceptional circumstances, and worker. The account will have been influenced by then only after documented discussion and agree- both what the patient thinks a professional wants ment with others, that such telephone calls are made to know and what the worker is used to dealing without the informed consent of the person being with. Such an account is clearly useful, but should referred. To the uninitiated, this preliminary be seen only as ‘the story so far’ (Box 7). exploration of the social context can seem radical

Box 7 Characteristics of ‘the story so far’ Box 9 Common origins of crises Dwells on the mental state Bereavement and loss Considers the differential diagnosis Illness of the self or others Refers to the need for medication Financial and job problems Includes risk management Accommodation difficulties Omits the social dimension Legal worries

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and fraught with risk. It may be feared that, like opening Pandora’s box, such enquiry might release Box 10 Questions to ask key informants further complicating, potentially dangerous and What do you think has happened? difficult-to-deal-with problems. However, it is Do you know why? important to consider how focusing on the wrong How were things before? issue and missing the right one can be even more Are you able to help? regrettable. Moreover, it can be reassuring to know Who else might help? that if an enquiry is made in a suitably sensitive manner, it is unlikely to provoke an avalanche of difficult-to-deal-with problems. dealing with urgent referrals are often under Thus, issues of confidentiality and invasion of pressure to make decisions quickly and move on. privacy need to be balanced against the real need to By working more slowly, the crisis resolution team understand how to help the individual concerned can sometimes identify and clarify the essential as appropriately as possible. It is important also to issues to be tackled, ensuring that interventions recognise the normal willingness of most people to are appropriate. be helpful and caring towards others, especially Despite the early contact with significant others, those within a particular social system (e.g. the at initial assessment the emphasis needs to be on family, workplace or informal social circle). In the point of view of the patient, rather than that of making the preliminary telephone calls, a great deal anyone else (Polak, 1970; Relton & Thomas, 2002). can be achieved very quickly with simple and Reference to Maslow’s hierarchy of needs (Maslow, general enquiries, coupled with careful listening to 1998) may be useful: some needs take precedence what is both said and not said in reply. It should be over others. It is important to work with the feasible to find out whether or not the person is patient’s own priorities: setting up another agenda willing to help further or knows of others it might be can prove futile. The first interview should both relevant to contact (Box 10). These initial telephone allow the patient to give a subjective account as calls might include going back to the original referrer, freely as possible and introduce the need for especially with patients already known to the connections to be made with his or her social service: indeed, for long-term patients the relevant systems. Which of these is relevant may become social system might involve other patients and other evident in what is presented spontaneously, and if mental health workers (Dickinson et al, 2002). so they should be noted for future elaboration. If Thus, in contrast to the usual practice of inter- nothing is revealed, it might be necessary to apply viewing the patients before any other action is taken, a checklist of direct questions to explore thoroughly the crisis and social systems approach is facilitated the possible ramifications of the presenting by time spent finding out more about a referral before problem. These questions are easily generated from the first interview with the patient. This might reveal knowledge of which social systems are most likely that it would be very useful to have present at the to be relevant and what are the most common first assessment others particularly familiar with the upheavals to be expected in each of these systems issues involved. (Boxes 8 & 9). The first interview is best done in the place where Once an initial assessment of the issues involved the patient is at the time of the referral, rather than has been achieved, it is useful to record in diagram- arranging for him or her to go elsewhere. Alterna- matic form the social relationships involved: the tively, if not already at home, it might be acceptable overlapping social systems that seem relevant, to take one patient home before a full interview. where the sources of difficulty are, where the The social context of the initial contact can be strengths remain, and what interventions are revealing, and knowledge about it might contribute indicated. This mapping exercise (e.g. Fig. 1) may be to an assessment. During assessment, the behav- particularly useful for in-service training. iour of patients and of significant others is often influenced by the social context of the assessment. Assessment in the real-life situation should Vignette 5 therefore always occur as soon as possible, before A 20-year-old female student who lives alone is important elements of the crisis have a chance to brought to the accident and emergency department by neighbours after an attempt at suicide. Mental evaporate (Sutherby & Szmukler, 1995). Once this state examination reveals depressed mood, command process has started, however, there is no advantage auditory hallucinations, thought disorder and in hurrying: a slow assessment can become the first passivity delusions. A provisional diagnosis of acute and most significant intervention. Time is a schizoaffective disorder is made by the duty doctor commodity a crisis resolution team can use to and, without the crisis resolution team, admission to advantage, especially during assessment. Others the ward is indicated.

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MCQ answers Multiple choice questions 12345 1 Understanding social context: aF aF aF aF aF a is irrelevant for Mental Health Act assessments bT bF bT bT bT b contributes to risk assessment cF cF cT cT cT c helps choice of neuroleptic medication dT dT dF dT dT d is necessary to reduce inappropriate in-patient care.

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