CRISIS INTERVENTION -_ THE BARNET EXPERIENCE

Dr. Lawrence Ratna

Crisis intervention is a service much in demand by users, carers and purchasers. It is the service most consistently demanded by general practitioners. Despite the intensity , regularity and universality of this clearly expressed need, many service providers appear reluctant and are unwilling or unable to develop such services. This is not to deny that a variety of crisis services has been developed. The fact is that they are patchy, often working in isolation, split off from the mainstream of psychiatry. Often they have to work without support and in the worst cases, they have to cope with hostile and sometimes actively destructive responses from colleagues and senior figures.

It is hard to explain why crisis intervention is seen as the bastard child of psychiatry. However, more basic questions concerning the clinical need for and the merits of crisis intervention are more easily addressed. There are three basic questions:

1. What is the demand for crisis services, and are there populations at risk?

2. What is the evidence that crisis services are: a) Clinically effective ? b) Cost effective?.

3. What are the logistics and the consequences of running the Barnet crisis service?

The demand for emergency care comes from many sources and from many causes. There is obviously a high degree of overlap, but the origins of the demand can be traced to three main groups - Psychososcial, Psychiatric and Behavioural .

THE DEMAND FOR EMERGENCY CARE

PSYCHOSOCIAL

1. Adverse events : a. Those with a previously healthy personality

b. Those with previous problems

2. Accidental crises: - Bereavement. Rape, Disasters, Post Traumatic Syndromes.

3. Social crises :- Marital Breakdown, Family conflict, Unemployment, Redundancy, Homelessness.

Abandonment, Breakdown in care systems

Abuse :- Physical, Sexual, Emotional, Elder Abuse

4. Reaction to physical illness

Crisis events have been classified into accidental and developmental. Accidental causes are chance events, ‘the slings and arrows of outrageous fortune’, such as car accidents, illnesses, bereavement and disasters like floods or fire. Developmental crises are related to the stage in the individual’s or family’s life cycle. These are psycho-social transitions engendering tasks, which if not completed ,store up problems for a later stage. Examples would be leaving home, getting married , having a baby, retirement etc. The relationship between adverse events and the onset of mental and medical illnesses has been extensively researched. The relationship in time between adverse life events and the onset of illnesses such as schizophrenia, depression and many others is now well established. Further research to establish this connection, such as the demonstration of vulnerability and protective factors in depression, has deepened our knowledge of the precipitants and predisposition’s that lead to the development of symptoms. A critical distinction needs to be made as to whether the adverse event was experienced by a previously healthy person, or if the victim was in a vulnerable state as a result of previous trauma or illness. Most of the literature on crisis, particularly the American literature, appears to have been written on middle class, previous healthy individuals who had undergone adverse events. Caution should be exercised in extrapolating their insights and applying them to crises experienced by vulnerable clients or those with mental illness or personality disorders.

PSYCHIATRIC

5. Acute psychiatric episode - Psychoses, Mania, Depression, Confusion

6. Acute organic states - Delirium tremens, Acute brain syndromes, Drug reactions.

7. Acute on chronic mental illness

a: Relapse

b: Psychosocial difficulties

The distinction between crises and medical emergencies has been much debated. Crisis theorists, such as Caplan, see the crisis as a stage in the evolution of a mental illness. They argue that if the crisis is not resolved or avoided, the victims descend into madness. Since the Coconut Grove fire, a number of studies has shown the value of early intervention in alleviating the symptoms of Post Traumatic Stress disorders. Psychological and social intervention is now a key part of any disaster management plan. As regards early intervention in illnesses, such as schizophrenia and mania, however, the evidence is less clear cut but few doubt the value of early intervention.

BEHAVIOURAL

8. The Suicidal

9. The Dangerous

10. Acting out

11. Addictions - Alcohol, Drugs

12. Statutory - patients needing admission under the Mental Health Act.

Whilst the literature is dominated by the psychosocial and psychiatric demand for rapid response services, in practice it is the behavioural group that produce the greatest demand. For example, a deeply depressed individual lost in the loneliness of a bedsit is less likely to get a quick appointment with a mental health professional than a woman who goes out and takes her clothes off in the High Street . The suicidal is the group most actively catered for in a variety of services. The violent tend to be filtered through the police.

This raises the question of vulnerability: are there identifiable groups that should be targeted for services?. Once again, they form four groups that shadow the earlier groupings. They are psychosocial, psychiatric, psychological and social. Much of the American literature and the literature on crisis by psychologists and social workers has focused on the psychological and psychosocial groups. In a psychiatric practice ,particularly in community care it is the psychiatric and the behavioural groups that dominate the demand for emergency services. Within this group, it is those living in high Jarman(1983) index areas where social problems overlap and amplify psychiatric or psychological problems which generate the greatest challenges. Whilst crises in these populations are common place, services are seldom well organised to deal with them.

VULNERABILITY

PSYCHOSOCIAL

Life events - redundancy, bereavement, disasters

Life changes - Leaving home, childbirth, divorce, retirement

Victims of assault, abuse, rape

Carers of elderly, chronic sick, single parents

Physical illness

PSYCHOLOGICAL

Victims of abuse - sexual, emotional, physical

Individuals with poor coping skills, low self esteem.

Lack of social or family support. Isolated individuals.

High stressed individuals, overloaded workaholics

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PSYCHIATRIC

Previous suicidal attempt

Chronic mentally ill - schizophrenia, manic depressive

Personality disorders

Addicts - alcohol, drugs

Learning disorder, Brain injury

SOCIAL

Neighbourhood problems , Social decay- High Jarman Index areas

Single, widowed, divorced

Housing problems , living alone, homeless

Unemployment, Social class IV and V.

Oppressed groups - Immigrants, ethnic minorities, elderly, the disabled

Disability - Deafness, Blindness, Paralyses, Disfigurement

The demand for rapid intervention is greater in the social and psychiatric groups. In practice, there may exist an inverse relationship between need and provision. Those in highest need , in deprived inner city often get fewer and poor quality services in comparison to middle class clients with psychosocial and neurotic problems. There may be two reasons for this: the middle classes are more effective in accessing and lobbying for resources than the dispossessed. Secondly ,service providers are more willing to engage with their problems which have a better prognosis and are more satisfying to treat. Clearly , there is a need to cater for these dispossessed populations and for these presentations (Ratna 1994).

Our second question is: what is the evidence that specialised crisis services targeted at these presentations are clinically effective, and perhaps more importantly, in these times of financial restraint, cost effective?. There are a number of controlled and uncontrolled trials of crisis intervention. With one or two exceptions, they conclude that crisis services serve to reduce admissions and thereby reduce the overall cost of the service. There have been five large controlled trials in the literature. They can be summarised as follows:

CONTROLLED TRIALS OF CRISIS INTERVENTION

1.LANGSLEY.D.(1969) - 300 patients randomised to conventional treatment and Emergency Family Therapy (EFT). Crisis admission was avoided in all the EFT patients and those admitted subsequently stayed a shorter time in hospital. At 6 and 18 month follow up EFT was as good or better in symptom control and social adjustment. EFT was 1/6th the cost of conventional care.

2.DECKER AND STUBBLEBINE(1972) - Two groups- conventional and crisis followed up for two years. Crisis therapy group had fewer admissions, shorter hospital stays, fewer readmissions and a lower suicide rate.

3.RATNA. L(1976) - two matched populations of 150,000 each, one with a crisis service and one without. The crisis population had 60% fewer first admissions, 45% fewer readmissions, less chronicity and a fall in the parasuicide rate.

4.HOULT.J.(1983)-Randomised patients needing admission. One group admitted, the other given intensive community treatment. Community care no worse and in some respects superior to hospital treatment. It was 25% cheaper.

5.BURNS. T.(1993)162 patients randomised between conventional and community based treatment. Both group clinically and socially indistinguishable at 6 weeks , with continuing improvement in both groups over time. Costs were 50% cheaper. There were fewer suicides.

Whilst each of these studies can be individually criticised, the unanimity of the findings is hard to ignore. These studies are buttressed by the uncontrolled studies and by clinical studies of particular forms of crises (Punukollu 1991, Dean & Gadd 1990, Muen, Marks and Connolly 1992, Ratna 1982, Parad & Parad 1968, Schwartz, Weiss & Miner 1972).

There is also clinical evidence that crisis intervention reduces the risk of developing mental illness. The research evidence falls into two main groups; first, the social research of Brown & Harris, and second, a large body of literature on the management of survivors of disasters. In their study, Brown and Harris (1978, 1986) found that crisis support is a buffering factor that prevents the development of psychiatric symptoms. Second a number of followup studies on victims of disaster all consistently show that crisis support reduces the risk of developing post traumatic stress disorder, depression and other psychiatric sequelae in the aftermath of major adverse events ( Joseph,Williams & Andrews 1993, Yule et al 1990, Raphael 1986). .

Pooling the evidence from a wide variety of reports from all over the world (Katschnig et al 1994), there can be little argument concerning the demand, the need for, and the clinical and cost effectiveness of well organised crisis services.

The Logistics of the Barnet crisis service.

The Barnet crisis service has now been running for 25 years. It covers the whole population of the London borough of Barnet in North London and an adjoining cachment area in Boreham Wood and Potters Bar. This service, unlike other crisis programmes serves all the emergency needs of the population over sixteen years of age (Ratna 1991). The total population covered is 340,000. It is sectorised into two main areas: the West sector of 130,000 is dealt with by Napsbury Hospital and the East sector of 210,000 is dealt with by a district general hospital in Barnet. It operates 24 hours a day, seven days a week, 365 days of the year. It. aims to see the patient in his home with his family within 4 hours of referral. 90% of referrals are seen within this time frame. 60% are seen within two hours. Delays are usually due to multiple referrals. The visiting team is a multidisciplinary team, consisting of a psychiatrist, a psychiatric social worker, and a community nurse. There is . continuity of care, the team will assess and treat the patient at home or in hospital, as deemed necessary

For the sake of simplicity, I will focus on the Eastern sector where I work. This population of 210,000, is served by a district general hospital which has a psychiatric unit with 28 acute beds and 12 psychogeriatic beds. There is a backup ward that is closed during the day and only open at night with 28 beds. There are four adult psychiatrists and one EMI consultant. The crisis service covers the care of the elderly mentally ill.(Ratna 1982, 1984) There are eight Junior doctors and a Senior Registrar. There are 16 Community psychiatric nurses and 12 social workers sited in the hospital who also cover for all the statutory work of the borough (Mitchell 1994).

There is no additional staffing for the crisis service. There is no distinction or specialisation. The same staff service the inpatients, clinics and all the routine services that a comprehensive service provides. The crisis service exists as an additional service, targeting patients presenting as psychiatric emergencies.. As an alternative to being seen in their own homes by the crisis service, urgent referrals can also be seen in emergency outpatient clinics , urgent domiciliary visits by consultants, or by social workers or nurses, so that there is a range of alternatives in service provision. There is also a large number of nurses, paid for by the Trust, sited in general practitioners surgeries, who are able to take on patients fairly quickly.

Requests for emergency assessments are received from general practitioners, social services, the police, casualty and from hospitals in and around the cachment area. The calls are processed by the medical secretaries during the day and the admission ward staff at night. Basic data on the case is collected, the computer and past files are consulted and time and place for the crisis visit is arranged. The doctor , nurse and social worker are contacted and the team is launched. During the day all staff are potentially available for visits. Out of hours there is a registrar, a nurse and a social worker on call. The Senior house officer is on call for casualty and the wards and a registrar is on call for the community. There is also a designated consultant on call. The team goes to the patient’s home and carries out an intervention . There is continuity of care and the team will remain involved, arranging for treatment in the community or in hospital, as deemed necessary.

The consequences of the crisis service

A comparative study (Ratna 1976) showed that following the implementation of the crisis service, admissions fell by 43%. This was partly due to a fall in readmissions, but the greatest fall was in the reduction of first admissions , which fell by 60%. As a result of greater support in the community, the level of chronic long stay fell. There was a relative fall in the attempted suicide rate, which was rising nationally at the time ,as was the case in the matched control population. More recent studies suggest that there is lower rate of recurrence following management of attempted suicide on a crisis intervention model. There was no change in the suicide rate at the inception of the service, despite the major reduction in admission rates. More recently we have been able to carry out detailed analyses that show the Barnet sector as having half the national suicide rate. The rate was 5.6/100,00 for all residents, 3.5 for patients who had contacted the service at some stage . This compares with a national rate of 11.4/1000.

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The cost of the service.

The Barnet crisis service differs from most others specialised emergency services in having no additional staff allocation. There is some increased cost in on call duties, travelling and communications, such as long range bleeps and portable phones. The savings come from the number of acute beds and in bed occupancy. Taking the figures of minimum bed requirements from those set out in the white paper, “Better services for the mentally ill” and focusing on the acute sector only, the Barnet sector should have 80 acute admission beds for a population of 210,000. It only has 28., leaving a shortfall of 52. Taking the cost of an acute admission bed as between four and six thousand pounds a week, this generates a saving of between 832,000 and 1,872,000 pounds a year in the acute sector alone. There is an additional saving. Whilst the rest of London’s psychiatric hospitals have a bed occupancy 130% , necessitating payments for extra-contractual referrals to find beds for their patients, Barnet, despite its lower bed numbers , has been able to take in ECR’s and generate funds.

Conclusion

Crises are a part of life. All services psychiatric, social, nursing and medical have to deal with a variety of psychiatric emergencies every day. There are many models of intervention : medical, social, psycho-social. The body of literature is large, the evidence for effectiveness, convincing Yet there seems to be a reluctance to organise, train, target and deal with these presentations within a comprehensive policy community care. A common argument cited is the strain imposed by such services on its practitioners and the subsequent phenomenon of burnout. As one who has been at the cutting edge of crisis intervention for 25 years, I can attest to the fact that the pressure stems not from the work but from the hostility of outside agencies. Arguably, for many professionals, crisis intervention is a difficult and daunting task. Like it or not, we all need to learn to deal effectively with patients presenting as emergencies. Given the potential rewards of crisis work and the desperate demand for it, it is clearly an area of psychiatric practice that needs more urgent attention and support, if the needs of the patient and of the community are to be effectively served.

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