Crisis Teams

The purpose of this paper is to critically discuss multidisciplinary team (MDT) working within a Crisis Resolution Home Treatment Team (CRHTT), whole systems working and how these impact on the teams efficacy. This will be done by demonstrating knowledge and understanding of influential theoretical concepts and relevant policy drivers. There will be an examination of current practices the author experiences working as a Crisis Practitioner within a CRHTT, supported by an analysis of pertinent literature. This will be synthesized to form a discussion about changes to practice that is needed and recommendations for future study. In conclusion there will be a reflective discussion of the implications of learning during this module for the advancement of the authors’ academic skills and professional development.

The National Service Framework for Mental Health (NSF) (DoH, 1999), standards 3, 4 and 5 in particular, and the subsequent NHS plan (DoH, 2000) instigated the creation of CRHTTs, with the Mental Health Policy Implementation Guide (MHPIG) (DoH, 2001) setting out the underpinning operational guidelines for their implementation. The National Suicide Prevention Strategy (DOH, 2006a) supported the development of CRHTTs and recognised the importance of close working between them and acute inpatient units, particularly concerning early discharge planning and its impact on of suicide reduction (Smyth, 2003). With the achievement of NSF targets (DoH, 2004; The Sainsbury Centre for Mental Health, 2006), the concept and delivery of home-based crisis care has become the norm for mental health services (DOH, 2006b).

There have been various attempts to define what is meant by a ‘crisis’ within a psychiatric context (James and Gilliland, 2005; Lillibridge and Klukken,1978; Roberts, 2000) although Caplans Crisis Theory (1964) is best known. This conceptual framework defines crisis as a time limited response to a life event which is not solvable by the individuals’ usual coping mechanisms. The symptoms of mental illness of those in crisis are regarded as signs that these coping mechanisms are failing. Caplan emphasised a community-wide approach to interventions with diagnosis being less important and treatment focused on problem-solving techniques and the person’s social network (Hubbeling and Bertram, 2012). The word Crisis in the Chinese language is translated to mean danger and opportunity (Greene et al, 2000) and, according to the theory, going through a crisis provides an ideal opportunity to learn new coping skills, whilst identifying, activating and improving those already possessed (AUTHOR, ????).

Despite the seminal importance of Caplan's work it has been considered dated because of its influence by Freudian thought (SCMH, 2001, pg2) and a reliance on disease concepts rather than health (Hunte and Morgan, 2008). Crisis theory is not cited in contemporary service literature (Anderson, 2006) and CRTT provision is not based upon it. However, although considered an atheoretical way of arranging services (Johnson & Needle, 2008), the MHPIG (DoH, ???) deals with the concept of crisis in practical terms rather than rejecting Caplans work (Anderson, 2006). But there is confusion over the real, or perceived, lack of clarity in the definition and understanding of what constitutes a crisis, with frequent tensions and conflicts within and between clinical teams as a result (Friedman, 2008; Hunte and Morgan, 2008). These maybe caused by different thresholds of tolerance or interpretations of crisis situations guided by personal motivations and/or agendas (Allen, 2010). Through implication of their name, there is a diverse expectation of functions that a CRHTT can or should provide which are not helpful for the team when focusing its limited resources (Onyett et al, 200?).

Ervin Goffmans (1961) study of asylums was one of the first sociological examinations of the social situation of the mentally-ill patient. He introduced the idea of 'total institutions', which included any type of institution, as places where individuals are isolated from wider society, in which they are all treated alike and their behaviour is regulated (Mac Suibhne 2011). All aspects of life are contained within this one organisation with the goal of the asylum to force the patient to adjust their senses of self. The consequence of this ‘institutionalisation’ (Davison et al, 2010) is to socialise the patient into the role of a ‘good patient’, which in turn validates a diagnosis of mental illness (Lester and Gask, 2006). Goffman illustrated that patients coped with confinement in lots of different ways and his work was key in drawing attention to the patterns of interaction that dehumanised patients (Mac Suibhne 2011).

Goffmans work has been influential within the fields of sociology, psychiatry and social welfare but has been accused of being biased and deficient (Weinstein, 1994) and viewed as paradigm of ’antipsychiatry’ (Mac Suibhne 2011) with the noticeable absence of the patient’s voice prompting the question whether it is more about Goffmans experience rather than the ‘inmates’ (Seale, 1999).Although there have been doubts about Asylums validity to current practice due to the changes that have occurred with Psychiatry since its publication (Weinstein, 1994), the author will demonstrate that this is inaccurate during this piece of work.

The work of Foucaults (1967; 1977; 1981) includes critical studies of various social institutions, including psychiatry, the relation between power and knowledge and his ‘discourses analysis’ of the past in relation to the history of Western thought. His historical account of madness is concerned with freedom and control, knowledge and power rather than disease and its treatment. He observed how the term ‘insane’ described a number of different presentations and was therefore a social construction, defined by the perceptions of society at a particular time according to flexible criteria.

Foucault postulates that the ‘medicalisation’ of madness is a more subtle form of power which subjects mental illness to medical intervention, regulation and ultimately control. Professional groups, such as Psychaitrist, assert to both understand human beings (knowledge) and prescribe how they should act (power). Using their established ‘scientific’ criterias they have the capacity to define what is normal and where deviance occurs (Foucault, 1967), therefore imposing how individuals should act and behave with the ability to confine and control those deemed ‘insane’ as the ultimate residing power (Jones, 2003). Foucault believes that this form of power has spread from enclosed, disciplinary institutions to society as a whole, creating a ‘disciplinary society’ (Foucault, 1977, p.209) and the ‘psychiatrisation’ of everyday life (Castel et al, 1982; Rose, 1998; 1999).

Foucault has been accused of over generalising in his historical accounts (Sedgwick, 1981; Scull, 1993) and his argument that there is no differences between kind community psychiatry and cruel confinement has been criticised for not being subject to empirical confirmation or denunciation (Porter, 1990). Although Foucault’s work is mainly about historical studies, he was also interested in the modern analysis of insanity and felt that the field of psychiatry was not as supportive of the mentally unwell as is claimed (Thomas and Bracken, 2004 – get ref.), with his work providing a significant critique of the subtle forms of power and manipulation in encounters between psychiatrists and service users in mental health care today.

The concept of illness behavior is any behavior undertaken by a person who feels ill to relieve that experience or to better define the meaning of the illness experience (AUTHOR, 19??). Parsons (1951) argued that illness is a form of deviance that is disruptive for society as the sick person is not able to fulfill their normal roles. He developed the concept of the ‘sick role’ (1951) as a way of understanding how the sick person relates to the whole social system and what their purpose is in that system. He made the distinction between ‘disease’, which involves bodily dysfunction, and being ‘sick’, which is to be identified and accepted as being ‘ill’. Being sick is governed by two rights; exemption from normal social role responsibilities and exemption from the responsibility for being ill, and two obligations; to want to get better as soon as possible and to consult and co-operate with medical experts in trying to get better (Parsons, 1951).
The sick-role accepts established medical symptomatology and diagnosis and therefore allows the sick person to take on behaviours conforming to the expectations of the medical system (Parsons, 1951). Assigning the Sick Role legitimatises a brief restricted state of deviance and verifies the legitimacy of illness and reasons to abandon temporarily responsibilities within society (AUTHOR, ????). The physicians’ aim of returning the sick person to a normal state of functioning defines the patient-physician relationship and enables them to hold the greater power, allowing them to exert leverage when encouraging compliance with medical procedures (AUTHOR, 1951). Thus the function of legitimasing illness and occupancy of the sick role places the physician in a position of control (AUTHOR, ????).
Critics have questioned the extent to which illness is motivated and the model's relevance to long-term sickness as chronic diseases are incurable and exemption from social roles is not possible (AUTHOR, ????). It does not account for individual behavioral variation or the variations within the patient-physician relationship and Parsons describtion ofmostly middle-class patterns of behavior which do not apply well to lower-classes especially when exemption from social roles is not necessarily feasible for the poor despite illness (AUTHOR, ????).
Material was sourced through a variety of databases used for literature searching. Quest was accessed via the authors education provider; Medline, Psychinfo, Cochrane and MyI Library E-books through the authors NHS trusts library services. Terms/phrases submitted for the searches were; CRHTTs, Crisis Teams, Home Treatment, power, Foucault, Goffman, Asylums, Parsons Sick Role, team working, MDTs, role conflict, professional identity theory, hierarchy, medical model, social model. In addition the author was able to access various texts available for professional development at his place of work.

Most research and evaluations of CRHTTs have with been concerned with being concordant with MHPIG criteria or the ability to reduce hospital admissions. The findings of studies comparing home treatment versus hospitalisation have generally found positive outcomes for CRHTT provision in terms of reduced hospital admissions and lengths of stay; equal or better service user outcomes and preference by service users and carers.

However, a small number of studies found no evidence of CRHTTs making any difference to admission rates with their efficacy when supporting older adults at home questioned. Some suggested that CRHTTs need to be compared with other methods of reducing hospital admissions, although there is a lack of established evidence base for these alternative service provisions. Although there is a preference to be supported and treated at home, a lack of consistency in CRHTT team members who visit making it difficult to develop a therapeutic relationships are a concern of Service User and Carers.
Successful home treatment services have raised the threshold for admission resulting in an increase in detentions under the Mental Health Act and rising levels of acuteness of illness, providing additional challenges to stretched inpatient services. Consequently acute wards are considered tougher and scarier places than ten years ago.
CRHTTs cost effectiveness to mental health services is borne out by the evidence although current CRHTT targets are criticised for their focus on outputs rather than outcomes and therefore placing numbers and costs above the needs of users.
Caplans work is not cited in contemporary service literature and research concludes that the model cannot be wholly transferred into the daily reality of clinical work but found certain elements to be useful.
Contemporary service policy reinforces cohesive integration between professionals as a requirement for the delivery of a ‘seamless’ service, but MDT working can both be a source of reward and frustration. Despite the concept of ‘whole system working’ pressures and objectives of different professions, teams and agencies mean more local, specific concerns can be prioritised. A lack of role clarity between different professionals and the defence of professional identities, practices and roles are shown to be obstacles to joint working. Teams which honestly discuss issues of power and hierarchy and respect the differences between its members are most likely to be successful.
Though a degree of fragmentation is evident in the studies of CRHTTs, direct conflict is not obvious with medical and social models appearing to co-exist and staff valuing the team approach and shared decision making. The NSF (DoH, 1999) and MHPIG (20??) discuss multidisciplinary team working, team approach and team decision making but neither provides a description or explanation of what these entail and assume that roles within a team are clearly defined.
Case Study 1.
During a night shift the author and on-call junior doctor assessed a client of the local ‘High Intensity Team’ (AOT) with a diagnosis of Borderline Personality Disorder who the author had known for over 10 years but the doctor had just met. The client was trying to initiate an inpatient admission despite having a care plan in place that clearly stated that this was not in their best interest and a rationale as to why including historical evidence. The author felt that home treatment would be a preferable option but the junior doctor disagreed. As per trust protocol this dilemma was run by the on-call Consultant, who was based in another locality, via telephone and they agreed with the junior doctor to admit. The on-call Manager (RMN trained) was consulted and they felt that the doctors decision should be adhered to.
Case Study 2.
Information obtained from Trust Network Performance of the organisation that the author works for shows that the local inpatient unit bed occupancy is the highest in that particular trust as is average length of stay. From a CRHTT worker this is to be expected given ongoing disagreements and disputes with the Consultant of the unit who has been accused of being resistive to CRHTT interventions and more concerned with their Units way of working rather than whole systems working.