Perceptions of a crisis service by referrers and clients

Abstract

There are many kinds of crisis service. Most are open only to people who have been diagnosed as mentally ill. They facilitate rapid admission to short-stay in-patient services with the back-up of multidisciplinary teams working in the community. Others attempt to keep patients out of hospital by providing support to patients and their families in the community. Several have demonstrated striking reductions in the rate and duration of hospital admissions without detriment to the subsequent health or social adjustment of the patient.

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10.1192/pb.16.12.751Access the most recent version at DOI:
1992, 16:751-753.Psychiatric Bulletin
Colin Murray Parkes
Perceptions of a crisis service by referrers and clients
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Psychiatrie Bulletin ( 1992), 16,751 -753
Perceptions of a crisis service by referrers and clients
COLINMURRAYPARKES,Senior Lecturer in Psychiatry, The London Hospital Medical
College, Turner Street, London El 2AD
There are many kinds of crisis service. Most are open
only to people who have been diagnosed as mentally
ill. They facilitate rapid admission to short-stay in-
patient services with the back-up of multidisciplinary
teams working in the community. Others attempt to
keep patients out of hospital by providing support to
patients and their families in the community. Several
have demonstrated striking reductions in the rate
and duration of hospital admissions without detri
ment to the subsequent health or social adjustment of
the patient.
The Tower Hamlets Crisis Intervention Service
(CIS) was set-up as a joint health and social services
project in 1976. A multidisciplinary team visits
families in crisis to assess their needs and, when
appropriate, provides short-term support in the
community. It differs from most other crisis services
in attempting to prevent as well as treat mental ill
health. It accepts referrals from a range of pro
fessional care givers and is not limited to people with
overt mental illness, defining a crisis as any situation
which creates distress in a family. Although the
team can make use of the full range of psychiatric
and social work services, the preferred method of
treatment is short-term family therapy aimed at re
inforcing or restoring the family as a support system
to its members. Most assessment and treatment is
carried out in the home. Case-notes are 'family' and
'problem' oriented.
This paper reports the results of an evaluation of
the service as seen through the eyes of referrers and
clients of the service.
The study
Information for this evaluation was obtained in three
ways:
(a) Systematic analysis of the case-notes of 118
clients referred for the first time to the CIS (94
women and 24 men) between January 1984
and May 1985.
(b) Interviews with 29 GPs. 30 social workers
(SWs) and 23 other professionals (82 in all)
who had made referrals to the service during
that period.
(c) Interviews in their homes with 107 clients of
the service referred for the first time to the
service during the period of study.
Findings
Of clients, 80% were women with 79% under age 40
(mean age: women 32, men 33). A half had partners
(40% married, 12% cohabiting) with 29% single,
15% separated or divorced and 4% widowed.
Reasons for referral given by the referrers included
"threatened separation of family member" 50%;
"suspected or actual psychosis" 39%; "threatened or
attempted suicide" 28%; 87% gave "depression or
distress in the family", and 18% other reasons.
Three-quarters were referred because of risk of
suicide, violence or psychosis.
Although a psychiatrist subsequently made a
psychiatric diagnosis in 79% of clients, psychoses
were diagnosed in only 13%. Other diagnoses were
personality disorder (21.5%); neurotic depression
(14%); anxiety state (9.7%); brief depressive reac
tions (8.4%); alcohol dependence or abuse (7.5%);
and phobic state (7.4%). Other conditions occurred
in less than 5% of cases.
More useful from the point of view of management
was the analysis of problems. Nearly two-thirds of
those with partners had major problems in relating
to those partners whereas 41% of those without
partners had suffered the long-standing loss and a
quarter the recent loss of an adult person to whom
they were attached. A third complained of social iso
lation or alienation from their families and a similar
proportion of alcohol related problems.
Problems with children were common and six
adolescents all had problems relating to their
parents.
Management
All clients were visited in their homes by a team of
professionals (usually two). In 60% a psychiatrist
was a member of the team, 55% a community psychi
atric nurse, and 52% a social worker. In addition
to the client other family members were present at
two-thirds of the initial (assessment) meetings (38%
spouses, 33% children, 16% parents, and 11%
siblings).
On average, families received 6.8 visits from the
team over approximately 12 weeks. In addition 10%
received an average of 4.5 individual psychotherapy
sessions. Antidepressants were prescribed for 13%
of clients, major tranquillisers for 6%, and minor
751

752
tranquillisers for 3.5%. Twenty-nine per cent were
referred on to other agencies, including 7% admitted
for in-patient psychiatric care for a mean of 44 days
each.
Evaluation
Effectiveness. Of referrers, 78% thought that crisis
intervention had ledto the action they had hoped for;
79% thought that distress in the family had reduced
or ceased; nearly a half thought that the risk of
further crises had been reduced and in a quarter the
need for psychiatric admission had been reduced or
eliminated.
Three-quarters of clients had found the service
"helpful or very helpful" and two-thirds, asked
"How have things been since the team stopped visit
ing?," answered "better" or "much better" (11%
said "worse"). Among 40 clients who were asked
"What do you think would have happened if you
had not been referred to the Crisis Service?", a
quarter said that they might have committed suicide,
a quarter that they would have become mentally ill,
and 10% that they would have left home.
Features most often thought to have contributed
to the effectiveness of the teams were support to
and increased understanding by the family and the
opportunity to talk through problems.
Efficiency. The annual cost of the service at the mid
point of the evaluation (1984-5) was £35,000or
about £300per family. This compared with the cost
at that time of a hospital bed of about £20,000but we
have no way of knowing how much time these people
would have spent in hospital if the CIS had not been
available and the unending pressure on in-patient
services in this district meant that any bed that is
freed-up from one source is quickly filled from
another.
Could similar results have been achieved by send
ing only one professional? The team argue that at
least two professionals are needed to meet the needs
of a family and to avoid undue médicalisation.By
sending a 'family' (the CIS team) to meet the client's
family they attempted to provide a system of care
which supports and educates, and to reduce the like
lihood that the family will be unable to cope with
future crises. In general this expectation is born out
by the results. Although half the families reported
'some', and 29% 'many', further problems, most
had been resolved without the need for further
professional help. Only 21% had been re-referred to
the CIS between discharge and follow-up 15months
later, requiring an average of only two further
interviews, half of them by one member of the team.
There has been no tendency for the CIS to 'silt-up'
over the years with long-term mentally ill patients
who are more appropriately helped by rehabilitation
services.
Parkes
Appropriateness. Ninety-three per cent of GPs, 97%
of SWs and 83% other professionals asserted that
the client's home is the most appropriate venue in
which to assess crises in the family. Only three care-
givers, two of them consultant psychiatrists, thought
'hospital' the most appropriate place.
Most GPs and SWs thought a psychiatrist the
most appropriate person to help families in crisis,
yet 40% of the teams did not include a psychiatrist.
Close study of the reports on 46 clients whose team
did not include a psychiatrist revealed no misdiag-
noses or mistreatments. None of these clients subse
quently required admission, day care or out-patient
care, and none were referred to the emergency clinic.
No clients or referrers criticised the service for not
including a psychiatrist although there were a few
criticisms that the team, by including a doctor, may
sometimes be medicalising normal life crises.
The short-term therapy was approved by half the
clients who thought the number of visits "about
right", a third would have liked more and 13% less
visits from the team; 91% agreed with the decision to
end therapy and were satisfied with the advice given
at that time.
Among 14 psychotic patients referred, six were
subsequently admitted for in-patient psychiatric
care, one referred to day hospital care and two
refused further visits and further action was not
deemed appropriate. The remaining five accepted
and seemed to benefit from the care of the CIS. It
would seem that, while many psychoses require
hospital care, some benefit from the family support
provided by the CIS team which was usually valued
even if it led to admission.
Equitability. The service was criticised on the
grounds that it does not accept referral of children,
elderly people, or those already receiving psychiatric
care (unless referred by their psychiatrist). Staff
argue that satisfactory alternative services already
exist for these excluded groups. They see the CIS as
complementing, not competing with other services.
It was also suggested that the service should be
open to clients without a family in Tower Hamlets.
This questioned the basic assumption of a family-
oriented service and caused the researcher to look
closely at the 34 clients whose families declined or
were not available to meet with the team. They seem
to have benefited from and valued the help of the
service as much as those with co-operative families!
It may be that those who lack family support are in
just as much, if not greater need, of counselling and
support but also that individual one-to-one counsel
ling would have been a more cost-effective way of
meeting their needs.
Acceptability. The CIS attempts to be acceptable to the
local population by visiting the client's home, oper
ating from a base in the community, encouraging

Perceptions ofa crisis service
non-psychiatric referrals and not including a psy
chiatrist in 40% of teams. Only one rcferrer thought
that a client had been stigmatised as a consequence
of referral and 55% thought that stigma had been
reduced (perhaps because psychiatrists, when pres
ent, often reassure families that the client is not
mentally ill). Even so, a third of clients had been
apprehensive about the first visit and 13% had found
this "difficult" (two-thirds, on the other hand, found
it "easy"). Clients from ethnic minority groups may
find the service less acceptable than those from the
parent population because of the cultural differences
that exist between clients and CIS staff (and staff of
most other services). One GP who works mainly with
patients from Bangladesh had made no referrals to
the service on the grounds that he did not think it
suitable for his patients and the proportion of clients
from Bangladesh referred to the CIS (3.1%) is sub
stantially smaller than the proportion in the parent
population (about 9%).
Accessibility. Most referrers rated the CIS as "easily
accessible at all times". This was most apparent to
social workers and other non-doctors whose direct
access to other psychiatric services is limited since
most only accept referral from a GP or other doctor.
The CIS is not currently able to provide 24 hour
cover and most referrers think this is unsatisfactory.
On the other hand, only 5% of clients were dissatis
fied with delays in setting-up the initial visit.
One referrer and several clients suggested that the
CIS should be open to self-referral. This would
improve accessibility but staff feared that it would
lead to overload and to inappropriate use ofa service
which prefers to back-up the open doors provided by
GPs, SWs and the existing emergency clinic.
If primary carers are to continue to control access
to the service, it isimportant for them to have a good
knowledge of it. Of referrers, 47% agreed that there
was a lack of publicity and, of the seven GPs who
had made no referrals to the service, five requested
further information and only one said that he would
"probably not" make a referral in the future.
Comment
The CIS serves a population who are younger and
more likely to be female and have partners than
most psychiatric in-patients and long-term mentally
ill people. It focuses, therefore, on a group who
753
may have special potential for the prevention of
mental illness in future generations. On the other
hand, the service may not be reaching the older,
unattached members of the community whose need
for psychiatric help is greatest.
In the absence of a satisfactory control group,
any conclusions drawn regarding the efficacy of the
service provided by the Tower Hamlets CIS must be
cautious.
Overall comments by clients and referrers tended
to be very positive and to reflect a high degree of
satisfaction with the service. The findings strongly
suggest that the service substantially reduces the risk
of suicide, mental hospital admission and family
break-up, while improving the family's ability to
cope with future crises. Working with the service
was also seen as a valuable training experience for
members of the caring professions.
Criticisms of the service were few. They included
a wish for more information to referrers and more
clarity in the information given to them about the
service. Several clients would have liked the support
from the service to have continued for longer and
thought, with referrers, that the service should be
made available to a wider range of clients and
extended to other districts. Doubts were expressed
concerning the ability of staff from the UK to
understand and communicate with families from
Bangladesh.
These findings have persuaded the DHS to con
tinue funding for a consultant in community psy
chiatry in the Borough. A new psychiatric service
for patients from Bangladesh is being set-up with
Sylheti-speaking staff and it is hoped that this group
will take part as team members within the CIS when
appropriate.
Acknowledgements
This study was carried out with the help of a grant
from the Research Department of the Department of
Health. Thanks are due to Dr Gillian Waldron for
carrying out the diagnostic assessments, to Diana
Brendenkamp for sensitive interviewing, and to the
clients and referrers kind enough to answer our
questions.
A full list of references and further details of the study are
available on request to the author.