Journal of Family Therapy (1981) 3: 177-186

A 24-hour family orientated psychiatric and crisis service

Dennis Scott” and Irene Starr?

Introduction The purpose of this paper is to describe a family orientated service operating from a National Health Service Psychiatric Unit. The Unit is attached to a District General Hospital which is required to provide a comprehensive 24-hour service to the local community of the suburban London Borough of Barnet. The paper presents a discussion of the reasons for developing such a service based on the concepts derived from the researches of R. D. Scott. Access to the issue of a patient’s interpersonal relationships is normally closed off by cultural and politically defined defences, termed The Treatment Barrier, and it can be demonstrated that the concepts of ‘point of access’ and ‘choice point’ can enable access to a human situation to be gained which is thus otherwise closed.

Development of the service In a traditional psychiatric service, patients are admitted to hospital at the request of the G.P., which is usually made over the telephone to the con- sultant. ‘The consultant will admit without having seen the patient, and without having seen him in the family setting from which he comes. A good many admissions take place as a consequence of an untenable family situation where the referred patient’s behaviour can no longer be tolerated by the family or society, and it is they who first attach the label of madness or mental illness to the person being referred for psychiatric treatment. Thus a consultant admitting an individual to psychiatric hospital is con- firming a diagnosis of mental illness which was first made by lay indi- viduals and endorsed by the G.P. and the opportunity to intervene to redefine the situation and the focus of treatment is lost. The family and the referred patient hand their problems over to the ‘professionals’ and thus

* Consultant psychiatrist. f Senior Social Worker at the Psychiatric Unit, Barnet General Hospital,

Wellhouse Lane, Barnet, Herts.

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0163-4445/81/020177+ 10 $02.00/0 0 1981 The Association for Family Therapy

178 D. Scott and I . Starr relinquish responsibility in attempting a solution when the problems are frequently social and interpersonal matters rather than issues of illness.

The Family Psychiatric and Crisis Intervention Service as it operates at Barnet Psychiatric Unit is the result of developments which first took place at Napsbury Hospital during the 1960s and 1970s against a back- ground of Ministry of Health and DHSS recommendations for psychi- atric services to remove the gulf between hospital and community and base themselves within their catchment area (Hospital Plan: Ministry of Health 1962), extending even further beyond a hospital base and into the community (Better Services for the Mentally Ill, DHSS 1975). Although physical constraints at the time prevented the operational base moving into the community, they did not prevent the philosophy behind these recom- mendations being carried out, and in order to do this, the service went out to the recipients in the form of a multi-disciplinary team of workers. This particular approach challenged traditional attitudes and assumptions about mental illness still further, and was not, therefore, without its critics.

Scott and his colleagues (1965,1967,1973) had observed the phenomena attendant on the ‘diagnosis’ and admission of a ‘patient’ and the effect of ‘closure’ on the relationship between the referred patient and his significant others. Once a psychiatric diagnosis had been made and admission taken place, a rift is created between patient and family often of irreparable and long standing consequence. (A more detailed discussion on the concept of closure follows.) It was these observations and research which led to a radical change in admission procedure in the psychiatric team headed by R. D. Scott in 1970, when a team consisting of a psychiatrist from the hospital and a social worker from the local social services department went out to see all potential admissions conjointly with their family or other significant relations in their own home, when a referral which it was not considered could wait for an out-patient appointment was made to the hospital by a G.P. The Crisis Team was later joined by Community Psychiatric Nurses and a Social Work Department based within the hospital and in 1973 was able to offer a 24-hour service delivered within one hour of a referral being received, to the whole of the London Borough of Barnet and Finchley (pop. 163 000). In 1977 the team moved into the Psychiatric Unit attached to the DGH in Barnet. A similar service operating from Napsbury Hospital for the Edgware/Hendon sector was started in 1975. These principles of operation have been followed up to the present.

Drawing on the techniques developed by Caplan (1964), the team first seeks to reduce tension in order to diminish the risk of closure and then to define the medical and social dimensions of the situation involving all significant actors in the drama. Only about one quarter of cases seen actually

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result in admission. If admission is indicated a contract is made with the patient and the family. They will all be engaged in family meetings soon after the patient has been admitted so that the reasons for admission are made clear and kept live and not assumed to be an obligation on the part of the hospital, not open to question. The majority of cases receive follow- up from one or more members of the multi-disciplinary team, depending on the skills required for a particular case, and the majority of these are engaged in short term work of up to four months. The results of this approach show that, from the introduction of the service in 1970 admission rates were halved from 38.2 per 10 000 in 1970 to 19.3 in 1974. Chronicity (i.e. stay in hospital of one year or longer) was reduced from 3.5 per 10 000 to 1.75 per 10 000 per annum. The incidence of attempted suicides was reduced after a period of three years of operation of the service, compared to the rate of the N.W. Thames/Metropolitan Region as a whole, which steadily increased.

The concepts on which the service is based are now considered in more detail.

The treatment barrier

All main stream psychiatry operates within a powerful social and political field. In so far as relationships between the patient, his key others, and professional staff are concerned, this field creates a barrier to treatment, the effect of which is to establish chronicity, to maintain illness. I term it the treatment barrier.

The treatment barrier will exist when a person has been pronounced to be mentally ill by an authority who ultimately is a doctor, whether the label is neurosis or psychosis. The patient and those involved with him are then in a field governed by political laws, social attitudes and cultural values. In the setting of a comprehensive service we, the professional staff, have to see, and if necessary treat, all comers presented by society to us. The forces governing the field are most powerful if possible admission is the issue (since unless they can afford to go privately patients requiring admission have to come to us). Thus we and our clients are then locked in a field from which it is difficult for either party to escape. But the same forces are at work in any community setting in which there is a diagnosed patient; then, however, they appear in a more subtle form, but one which can, I believe, nevertheless provide a very effective barrier to treatment.

Thus the treatment barrier is the barrier through which we must penetrate before treatment which takes account of relationships can begin.

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It should not be confused with the defence systems described by psycho- analysts. The following is an example from the hospital setting: The parents come to see the doctor about their son who is in hospital. The son asks, ‘Can I go home?’ Parents: ‘We will have you home when the doctor says you are well enough.’ Doctor: ‘He has no illness for which we need to keep him in hospital. It is between you and him whether he goes home.’ The parents attack the doctor: ‘But doctor he is ill; he stays up all night playing his guitar and stays in bed all day. We cannot have him until he is well.’ Doctor: ‘It seems that it is the way he behaves you cannot stand, and that is why you do not want him home.’ ‘But doctor, he is our son and we love him, we want him to get well.’

Eventually, if the family show feeling, get angry, cry, begin to admit some real difficulties in their relationships, then the treatment barrier has been penetrated. If they succeed in forcing everything back onto the doctor in terms of ‘illness’, then the barrier has not been penetrated.

We may note that if we push such a confrontation far enough, the family may seek to invoke the political forces associated with the laws, written and unwritten, which govern mental health. For instance they might report the psychiatrist or the team to the local M.P. and try to get them whipped back into line and become ‘proper doctors’. This is an attempt to ensure that the painful issues sealed off by the treatment barrier do not emerge, In this way family therapy, conducted in the setting of a compre- hensive service, differs considerably from that existing in special centres which can pick and choose their clients, and whose clients can choose them. It may well be that society regards it as a violation if some forms of relationship are considered to be relationships rather than a form of illness, and for our part there are some forms of relationship which should go before the courts rather than the psychiatrist, though the issues are usually too subtle for the legal arena.

The service so far developed is designed to put therapists in the most advantageous position for gaining access to human relationships which may then become available for therapy. The following are some of the concepts subsumed under the general term treatment barrier :

The cultural image of mental illness

The cultural image of mental illness (Scott, 1973, Part 2) is a set of values governing our attitude to mental illness in the West, and governing the treatment barrier. This image sees the psychiatric patient as suffering from a form of illness for which he is not responsible, yet since mental illness touches the core of the person more than is the case in most forms of physical illness, the patient is seen as lacking responsibility for himself whom we as the staff are obligated to treat. This obligation is seen as not

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being open to question. If we accept this position it enables both the patient, and the relatives, to deny that they have any agency in the situation. The staff now become responsible not only for the patient, but for the relation- ships which exist between the patient and his significant others.

Point of access and the choice point If we regard human relationships as being of central importance in the way in which we can help our patients and others of importance in their lives, then we require to obtain a point of access to the relationships which the participants have with themselves and with each other. Once access has been obtained choice can be introduced into a situation in which, as we have described, choice and the acceptance of agency have been abdicated in favour of a disease process. Thus we can begin to hand back agency to those concerned in face of a system which favours abdication.

Let us take as an example a patient seen at midnight a year ago for whom a point of access and a choice point were clearly open at the time of contact.

In this case the crisis team were called out during the night to see a woman whose marriage had broken up. She was in real pain and was threatening to take an overdose. After exploring the situation and gaining contact with her she was told that she had a choice: she could take an overdose and thus throw away responsibility for herself, or, if she so decided, it would be possible to arrange for her to have help from the team to live through and to find a way out of her nightmare of pain and grief. If she took the former course it would be likely to lead to a situation which would make it difficult for her ever to get real help, since in taking this path, she could become a chronic patient-a person who became habituated to seeking this way out of the pain in her life. She chose to face it and after spending a long time during which she felt herself to be in a tunnel whose exit was blocked by her mother, she managed to emerge and to proceed on the road of her life.

Usually, however, the points of access have been closed off by the time a psychiatric casualty presents to us. The process by which the real situation becomes closed off we term ‘closure’ (Scott and Ashworth, 1967).

Closure When a crisis threatens it is likely that before we have even seen the identified patient and his significant others the pain and stress between them will have led to some degree of dehumanization of their bonds of relatedness. The participants shut off and close themselves to what is

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becoming unbearable ; this especially concerns tender feelings, as it is these that can hurt most. Here it should be noted that the family, if asked what is the worst thing which has ever happened to them say, ‘It was when Johnny broke down.’

The dehumanization means that a disconnection (Scott and Ashworth, 1965) partial or complete, has occurred in bonds of relatedness. The dis- connected elements of relationship now become unrelated entities which by a general consensus are seen in one particular family member. This disconnection can happen quite suddenly when tension and pain pass a critical point. The disconnection is achieved by severance (Scott and Ashworth, 1965) of bonds of relatedness instead of by the more normal mode of separation attended by sadness and depression.

Disconnection is between the response and the interpersonal situation which has elicited it. An example is given in the r61e play described below designed to illustrate penetration of the treatment barrier. This re- enactment concerns an actual case of a mother and daughter about one year after the daughter’s husband had died. The mother then sought to capture her grieving and vulnerable daughter in order that her daughter might now devote her life to caring for her mother. The daughter reacted very strongly against this move by her mother, and the mother feared abandonment by her daughter. This led to great fear on the part of the mother and to intense emotional pain through the threatened rejection by her daughter. But she disconnected the pain and fear from its interpersonal source. She thought that the pain and panic were due to cancer.

Thus do disconnected bonds of relationship become symptoms. In this respect the symptom represents a social death of an aspect of the relation- ship between the daughter and the mother. A bond of love and trust can become a symptom. It is in fact a partial identity murder. This led the daughter, already feeling guilty about her hostility to her mother to feel much more guilty and the mother to become much more demanding in a crooked way. Thus a crisis developed and the doctor was called in to give his official confirmation that the panic and pains the mother complained of were symptoms of mental disorder. This led to the patient being sealed off in the psychiatric space, a space in which the disconnected bonds of relatedness now have official status, and are the responsibility of the doctor.

The establishment of chronicity

In standard psychiatric practice symptoms which have arisen through severance are not related back to their source. Unless they are so related

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they cannot be resolved, and chronicity is thereby established. Standard practice thus enables a massive evasion of reality by all concerned.

Closure can be a point of no return. As has been described, a symptom in the above sense represents a partial death of that person as a social being. Being in the psychiatric space makes that death official.

There may be no way back. This applies particularly in the case of sensitive crisis prone families, like those of schizophrenic patients. Once they have reached the apparent safety of closure--‘Now we know what is wrong. We know who is ill’, the family may never again risk seeing the patient as ‘well’, however well he may be.

At the heart of all this seems to lie an instinctive recognition that mad- ness can threaten the most precious thing of all-the spirit which mediates human relationships, without which we have lost our souls, and we can no longer care for or love another. Life then loses its meaning.

The gaining of access

How can we gain access to a situation of threatened closure, or to one in which the patient has actually been closed of f in the psychiatric space? We commonly find patients giving all sorts of reasons for being ill and excusing themselves from life and any responsibility for their own lives and only ask that the doctor or nurse make them ‘well again’. ‘But I’m a schizophrenic, you should understand me doctor, I’m ill.’ This is one of the standard phrases quoted by many people who have entered the medical limbo and lost human contact. This, many of us see as a defence against ‘treatment’. They are, in other words, preventing us from ‘making them better’. At first we are met by a wall of impenetrable inertia and often give up and treat the patient as a schizophrenic for the rest of his life. We feel that we will never be able to break through the barrier and see a real person instead of a ‘standard patient’. We must, at this point ask ourselves how responsible we-as members of the caring profession-are for the response with which we are so often met. Already, we have indicated how often we are involved in confirming a disconnection between the patient and others, and between them and ourselves. We may now take a closer look at this fundamental issue which always involves dehumanization. How much do we, by our mere presence as doctors and nurses, seduce a person into being ill for us and for society? Regrettably there can be no doubt but that this is very frequently the case. It is a violation of our professional standards to have an intimate relationship with a patient. This ethical code may be based on an awareness that if, for instance, we had intimately known somebody before they became a patient it would be wrong to seduce,

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in any of its many senses, a person who is at a vulnerable stage of their life and that we must in consequence act professionally. This statement is in fact an access point-an opening through which we can view our defences and see why we have them. When we act professionally we stand back from human contact and can be objective and rationalize situations which may be heavily charged with emotion, such as grief. It is, of course, essential not to get bogged down and entangled in the emotions of our clients, or we only succeed in recharging the situation rather than rationalizing it and so being able to play on positive aspects. But if we cannot give of our real selves how far can we ask patients to become people? It is small wonder that we are expected to perform miracles and to have superhuman powers when we can sit in a room filled with deep sorrow and not even consider crying.

Our place as professionals in the treatment barrier was previously presented when the concepts on which it is based were discussed. From what has been said in the present section we may see how, if we consider a patient as being inaccessible, he is likely to have as much right to see us in this way. There is evidence that healing takes place through genuine human contact between the patient and therapist at critical points of access to the patient’s wounds and vulnerabilities.

The following is a description of a r81e play of a situation common in everyday practice. It shows in condensed form the essential features which may occur when we achieve a penetration of the treatment barrier. We should note that once we have achieved a penetration we may decide to stop there, or we may decide to enter more deeply into the human issues of relationship which have emerged. If the latter is the decision then we enter a realm which is the subject of most work on family therapy.

Description of a rdle play illustrating penetration of the treatment barrier

At the conference workshop we showed a video tape which was a r81e play of an actual case. The nature of the way we visit a family in their home in the midst of crisis precludes our introducing video recording equipment no less for ethical than practical reasons.

This is the case of an elderly widowed mother who constantly complains that she is ill and demands an excessive amount of time and attention from her daughter, the G.P. and the community by making numerous phone calls. Physical investigations which proved negative do not satisfy her and her behaviour creates intolerable stress for the daughter, who along with other members of the community, are putting pressure on the G.P. to effect some action which will put a stop to escalating anxiety within and

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about this old lady. Admission to psychiatric hospital would be a socially acceptable way of doing this, and it was at this point the crisis team, con- sisting of the two authors (subsequently referred to as the therapists), was called.

When we arrived, the daughter presented us with the fact that her mother was sick and in bed. In order not to accept this r61e (obviously having had proper information from the G.P.), we did not treat her as a sick person, interviewed in bed in the sick room, but we resorted to her well side and asked her to join us in the living room, thus challenging the sick label attached to the mother. This created some anxiety in the daughter who responded by protecting her mother (i.e. protecting mother, pro- tecting mother’s sick r61e which enables them both to close off to the real issues and concentrate on ‘symptoms’). The therapist sought to gain access to the mother through her symptoms by asking her to tell him about her fears, suggesting that she was afraid of being left alone. Again the daughter intervened to maintain the stutus quo, persistently confining the discussion to the area of illness which absolved her from responsibility, i.e. mother complained daughter doesn’t visit, daughter responded by complaining of mother’s demands. The therapist asked the daughter what she thought her mother wanted from her, to which she replied that the doctor should know as she was ill and needed looking after in hospital and that the mother could not say what she wants because she was sick.

The therapist suggested that the mother wanted to claim her daughter’s life. The daughter released some of her emotion and anger at this proposal which had acted to achieve a ‘point of access’ into the human situation. The family attempted to close it up again by mother complaining she did not feel well and her daughter accused the therapist of upsetting mother. The therapists worked to keep the situation open and the emotions live at the same time being sensitive to the support mother and daughter needed in order to tolerate the situation. The daughter was encouraged and enabled to talk about her own life, the pressures she had, particularly since the recent death of her husband who had provided support for her in relation to mother. Mother was asked to say something about the effect of the loss of her son-in-law and she, too, was enabled to talk about her sadness and sense of loss.

Here a point of access to their loving feelings was reached, which they tentatively explored. The daughter expressed surprise about mother’s feelings and mother revealed that she had kept them to herself as she had not wanted to further upset her daughter.

One may posit that the treatment barrier had been penetrated and the human issues could now be brought out and better tolerated by mother

186 D. Scott and I . Starr

and daughter. When the therapist again brought up the question of fear and abandonment, the mother and daughter were more able to talk about their real needs, particularly the daughter who was, now, able to state her need for her own space and both moved nearer to a position of negotiation over the amount of time the daughter could give to her mother, a choice point having been reached. In the final stage of the inverview, the therapists fed back to the family what they had observed had been happening between them, redefining the situation from an issue of sickness to one of human relationship and a discussion followed on how to best meet the real, acknowledged needs took place.

Conclusion

The service which is described in this paper and the concepts on which it is based grew out of research in family therapy. The service has now become a comprehensive service to the London Borough of Barnet. In this setting family therapy or an approach derived from it operates in a powerful socio-cultural field governed by what we term the cultural image of mental illness. This field has rendered it necessary to define the Treatment Barrier and to find practical means of penetrating it to the human relationships which have so often been abolished by it.

I n a workshop designed to present the principal concepts and the inter- ventive technique, r81e play can bring alive, for the participants, the dynamic pressures on a psychiatric team, to make a family problem into one of a ‘psychiatric patient’. T h e experience of these pressures, alerts workers in the field, to the need for direct human contact and openness in the confrontation of the issues.

References

BETTER SERVICES FOR THE MENTALLY ILL, DHSS (1975). CAPLAN, G. (1964) Principles of Preventive Psychiatry. London. Tavistock

HOSPITAL PLAN, Ministry of Health (1962). SCOTT, R. D. (1973) The treatment barrier: Parts 1 and 2. British Journal of

Medical Psychology, 46 : 45-67. SCOTT, R. D. and ASHWORTH, P. L. (1967) ‘Closure’ at the first schizophrenic

breakdown. British Journal of Medical Psychology, 40: 109-145. SCOTT, R. D. and ASHWORTH, P. L. (1965) The ‘axis value’ and the transfer of

psychosis. A scored analysis of the interaction in the families of schizophrenic patients. British Journal of Medical Psychology, 38: 97-1 16.

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