Providing Child and Family Mental Health Services
with Minimal Resources:
In The Peripheries of Excellence
By Nick Child
The then European Regional Council of the World Federation for Mental Health arranged its conference in 1991 in Prague on the theme of Family Systems Health. Given the opening up of the old USSR and a Czech contact through AFT, I thought it would be fun to go and do a workshop on what we had been doing in Scotland.
The main result of the workshop was the interest of Dariusz Baran, Polish psychologist and politician, who saw the abstract and title. Since he asked, I wrote up the workshop into a paper. He visited us, and, much later, we visited Poland. I revised this paper for our 1998 visit and Dariusz got it translated into Polish. A great honour!
I retired in 2003 from the welfare state system - from CAHMS and the NHS described in this paper - to work part-time in a non-statutory sector. In that context my values and approach had to change radically from those described below. The government is not paying a solid salary even if you are not seeing high numbers of patients all the time; the client is in charge of their own referral; and the agency is not in any position to try to team up with other agencies. Given how ingrained my welfare state thinking was, this change was hard. As a powerful NHS consultant, my beliefs had many benefits in serving a big population with minimal resources; but they would not have been good for all purposes and people. Remember that the present tense in what follows applies to 1991.
The then European Regional Council of the World Federation for Mental Health arranged its conference in 1991 in Prague on the theme of Family Systems Health. Given the opening up of the old USSR and a Czech contact through AFT, I thought it would be fun to go and do a workshop on what we had been doing in Scotland.
The main result of the workshop was the interest of Dariusz Baran, Polish psychologist and politician, who saw the abstract and title. Since he asked, I wrote up the workshop into a paper. He visited us, and, much later, we visited Poland. I revised this paper for our 1998 visit and Dariusz got it translated into Polish. A great honour!
I retired in 2003 from the welfare state system - from CAHMS and the NHS described in this paper - to work part-time in a non-statutory sector. In that context my values and approach had to change radically from those described below. The government is not paying a solid salary even if you are not seeing high numbers of patients all the time; the client is in charge of their own referral; and the agency is not in any position to try to team up with other agencies. Given how ingrained my welfare state thinking was, this change was hard. As a powerful NHS consultant, my beliefs had many benefits in serving a big population with minimal resources; but they would not have been good for all purposes and people. Remember that the present tense in what follows applies to 1991.
INTRODUCTION
Having done all my training in Edinburgh, Scotland, I have worked for two decades as a Child and Family Psychiatrist in the National Health Service (NHS) sector in Lanarkshire, based in the Motherwell "Child and Family Clinic". The phrase "Peripheries of Excellence" implies that peripheral settings can be as excellent in many ways as the centres are!
What I have to say is mostly obvious and not original. It's really just one type of good community psychiatry. I do not propose it as absolute truth - if a better one suits you, disagree with me and use it. This account was developed for an international WFMH European Regional Council congress in Prague, 1991, on the theme of Family Systems Health. In its workshop format, this material was presented with time for small group discussion in pairs in order to aid understanding, explore similarities, differences, equivalents, applicability to other countries and work setting, etc. There was not time to go into clinical details of work with families. In summary, if you saw us at work, at first you would think it's a lot of routine live team Family Therapy. Much of it is - a mixture of Milan and Robin Skynner. But, for providing a comprehensive Mental Health service, we have to be simpler, broader and more creative, open and flexible. We call it a Family Systems Approach. We might now call ourselves Systemic Practitioners, applying family systems ideas by other helping professions than qualified Family Therapists. We are not a Family Therapy service even if it looks as if we are. There are other reasons for this terminology: we find "therapy" is a mystifying and medical term, and we work with other systems than just families.
GENERAL WORK CONTEXT
Geography:
Lanarkshire lies to the East and South of Glasgow, and 40 minutes drive from Edinburgh - both being "centres". It is a mixture of run-down deprived urban industrial towns, small towns, new towns, and rural areas. I work in a small multi-disciplinary team that serves one of the three districts (each with a population of about 200,000). We share nice premises with one of the other similar small district teams. From 1999, we re-organise in parallel with the local authority re-organisation into North and South Lanarkshire. Two pairs of teams will serve each of these, leaving the team I work in to serve only the urban part of the previous area, population about 150,000.
Services in the District:
Only by 1991 and after years of marathon ups and downs did we pass a "minimal basic" level of staff in our teams. Now each team is composed of social worker, clinical psychologist, nurse therapist, child and adolescent psychotherapist (in ours), and consultant psychiatrist with a secretary and sometimes trainees from each of the disciplines.
Who else serves this district?
Britain is still a welfare state (despite radical cuts and changes set going by Mrs Thatcher in the 1980s); Lanarkshire has deprivation, high unemployment and a traditionally socialist population (including immigrants from E.Europe). There is therefore little private practice or private education. Even the major changes set going by the government to make the welfare system more business-like are not intended to alter the "service for all and free at the point of delivery" approach to health, social and educational services. These are provided by two state authorities (from the NHS in the form of General Practitioners (GPs) and specialist hospitals and services from Lanarkshire Healthcare NHS Trust (as it is now but again to be reorganised by the Labour government to include a stronger involvement of General Practitioners), and from Local Government: Strathclyde Regional Council, which was the largest local authority in Europe, they say, has been disaggregated and (intentionally) disorganised so that North and South Lanarkshire have taken over, splitting and complicating our carefully coterminus team catchment areas in the process. So, also serving our new smaller district, are the following: (collected mainly in local Health Centres) 80 GPs, also known as "family doctors", with Health Visitors and Nurses; 70 social workers in 3 Area Offices + Social Work Day Assessment Unit + other kinds of social services; 17 educational psychologists serving numerous schools which have their own Guidance Teachers on the staff; 1 main District General Hospital (including Paediatrics and a small Hospital Social Work staff who do much of the work we would have to do there if they didn't - eg parasuicide); 1 adult psychiatric hospital (including 6 consultant psychiatrists for the district, adult clinical psychologists, Community Psychiatric Nurses and an adult day hospital etc next door to us, along with CMHTs and Psychotherapy service more recently.
The Job:
Our task is not just to set up our private practice stall until a handful of patients pay you a living - that's easy, and does little for spreading mental health. Nevertheless, in some ways it's not a lot different. Like most British Child and Family Psychiatric services, our core task is to take referrals sent to us. Of about 280 referrals a year, 50% come from GPs, and most of our time is taken up with conjoint family appointments, team screenings and meetings, phoning, letter-writing etc. But our task is actually to provide a comprehensive service to the child and adolescent population in the district, age range 0-18 years plus. This is a mountainous task! Taking the usual rates of defined "psychiatric disturbance", there are in Lanarkshire as a whole, about 6000 children, and 1500 adolescents with significant disorder. If you think of these as members of families, then there are some 20,000 family members involved too. And what about a more positive (salutogenic) approach to support "mental health" in general, not just around "cases"? There is an English phrase about "mountains and molehills" - we're like a mole with a mountain to dig away!
In the workshop, at this point, small group discussion was asked for on these aspects -geography, district character and services, and work task.
FEW RESOURCES BUT ONLY ONE DEMYSTIFIED JOB
Minimal Resources.
Compare our minimal team, the task and the size of the population again. We have no day or in-patient units at our disposal; there are no additional specialist adolescent, psychotherapy or other special services for this age group in the district - we take the whole range of problems. We have a concept we called "the Gatehouse Combination": minimal staff dedicated to respond to "community" well enough to limit and control the need for the more intensive in-patient and day units. We cannot be an "open door" to families, responsive and active in liaison with referring and other helping agencies (which does not mean necessarily travelling to see them). The aim is to be responsive to families and professionals and always sort something satisfactory out. This requires stamina and long-term single-mindedness. But there are benefits of starting with almost no services - we have turned deprivation of resources into freedom to develop a progressive service. In a fresh geographical area, there are no conflicting old style set-ups to take on, and no rival mental health services - there are advantages to totalitarianism!
Which Institutional Needs Take Priority?
Though CFC does have trainees, we are pleased not to have the functions the "centres" have to carry - big departments, in-patient units, being one of many departments within big hospitals, running university courses with constant mainline teaching and training responsibilities, local and national academic and professional committees, research, conferences, extra-mural courses. In my view, these extra organisational demands require my "central" colleague to do six jobs compared with my one job, providing a service. Where my colleague in the "centres" is primarily attached to all those "central" institutional demands, the "peripheral" person is primarily available and attached to client & other agencies - the community is my "institution". In addition, the benefit in a "periphery" is that it is easier to set aside professional identities and barriers so that you can go for what's useful & works instead.
De-medicalise and De-mystify.
Another main strand for us is to de-medicalise. I have argued (see references) against the attempt by child psychiatrists to seem to fit everything that moves into "International Classifications of Diseases! That we know we are working with "multi-factorial" matters means that our field has to be multi-disciplinary and multi-agency. That we know that the key factor in causing disorder is (unique) "predicaments" and "relationships" (particularly family relationships) means that we are not in the realm of biomedical disease. Therefore other labels are valid and perhaps the best ones are those of ordinary language (eg a conduct disorder would be better described as being naughty, or out of adult's control etc). I suggest instead that the doctor/psychiatrist's authority and skill is (notionally) in diagnosing "health" and moving on to understand and help with "problems of living" and "predicaments", again finding that ordinary language is best. Similarly, other disciplines' authority can be recast: social workers can decide when compulsory measures of child-care are not required; the psychologist can say that no special testing or educational or treatment method is needed. Even the word "therapy" we don't use because it is unclear, medical, mystifying and unacceptable to the local culture. But problems are no less serious for being responded to like this - people are so distressed they would prefer that they were bio-medical! So our "mountain" is a shared "mountain", shared with other disciplines and agencies. The field of helping "problems of living" is everyone's and no-one's. 95% of families don't need special help - that's because people and families are usually able to sort their own lives out without the help of any professional. (Perhaps where the "peripheries" allow us to de-medicalise and de-mystify, it is the "centre's" task to do the opposite: to sustain and develop professional mystification! It is the establishment's task to change slowly and only when it is persuaded of anything new. Maybe these are necessary opposite parts of the system!)
Pairs were to discuss their understanding of this and compare what resources they have, the number of jobs per person they're expected to do, the possibilities for de-mystifying?
CONCEPTS
I dislike abstract concepts in general, and my tendency is to do away with any theory. But I realise that I do have theory. Concepts are also what conference attenders and article readers tend to take away and use. And I realised that, in the early years in Lanarkshire, the concepts served me well, providing firm guidelines in a difficult and unsupportive context. But as colleagues came and contributed their own ideas and work, the real thing makes the concepts insignificant and forgettable. This must happen to an architect or town planners' "blueprints" when the house or town is built and populated by real people inhabiting what was originally just an image in the mind or on paper. In the absence of being taught anything suitable in my medical and psychiatric training, my theory had to be imported from outside it. Then, since noone understood it, I had to adapt it too. It came from the (relatively unknown Scottish) philosopher John Macmurray's ideas of "Self as Agent" and "Persons in Relation".
Cybernetic Ideas.
The result is basically a rather cybernetic model that amounts to a simple "systems" theory of "people with tasks and problems, one or more other people with solutions, and "inner persons", all of whom may get into inter- and intra- personal conflict which then becomes a different category of problem itself, presenting in direct or disguised forms, requiring methods of inter- and intra- personal conflict resolution which can be by an enabling process (helping the person to cope with their own problem) or by a "detaching" or "abling" process (one person taking the problem away from the other), but often by a disabling process (enabling being blocked). Simply, problems are solved by integrated solutions and sustained by unintegrated solutions, for example, an individual being "in two minds", or two people/ parents disorganised or in conflict, or two helping workers or agencies in conflict. Of course, some problems are themselves solutions from a systemic viewpoint.
Problems of Living.
On this basis, I link "family problems of living" through the main agencies (serving children) to the multi-disciplinary team of doctor/psychiatrist, social worker and psychologist. Problems of living organise and present in, or "as if" they are in, three main groups - "bad" (social need), "slow" (developmental or educational need), and "ill or mad" (medical or psychiatric need). This mirrors (in our culture in Britain) the three main front-line agencies, each with free access within the welfare state: the social services, schools (backed up by educational psychologists), and general medical practitioners. In our case, provided jointly by the two main authorities (Local Authorities, and Health Boards), the specialist services used by the front-line services finds the three aspects and front-line agencies reflected in the team. Each discipline has a notional responsibility for keeping in contact with their respective front-line agencies, and accounting to their respective employing authorities.
But, as outlined above, each discipline is not primarily trying to increase the power and realm of their own discipline - as they would be in the "centres". They are integrating their different specialist authorities more to diagnose the absence of biomedical disease, the absence of need for special developmental assessment or educational provision, and the absence of need for measures of child care", than to try and label and claim them for their own discipline. Once these concerns are authoritatively (though often not explicitly) put in their place, the field of offering to help work out what the problem may be is addressed. This field of problems belongs to everyone and noone and includes the possibility of other agencies being involved (not just statutory, of course). This then is what can be called "family-systems work", though preferably this common field should have no name, lest it be mystified or thought to be claimed by one sector as opposed to another. Any term that includes the word "therapy" is not appropriate for this reason.
For me, this theory of people and problems leads to an egalitarian, co-operative, multi-disciplinary, and multi-agency, team approach. It is a more accurate conception of the traditional medical language of "psychiatric disorders" being "multifactorial" and requiring "multidisciplinary solutions". The team, while fully aware of the professional task and contract, is firstly people and secondly professionals - the special professional and personal skills and characteristics serve the collective purpose of the person and team.
A number of other more metaphorical images and ideas link to these concepts. For example, the story of the Hare and Tortoise has wide application to how people of all kinds can be enabled or disabled - to what profile to take in organisation and training of Family Therapy, in relating to local agencies, in attitudes to client individuals and families, to team colleagues and trainees.
Family Systems Approach (or Systemic Practice)
Other concepts are more commonly known. A family systems approach is basically human common sense which experience teaches - better than words and conferences! A systems approach considers the individual as a system and sub-system of family (and other groups), the family as system and sub-system of wider systems and (when family functioning "fails" to contain the problem) agencies. The features of the method of work are those most highly developed in the Family Therapy approach - the family system is considered to be the case; one key-worker and key-agency allows the system and work to be integrated and worked with as such where possible. Where multiple agencies are involved, notions like "minimal sufficient network", and skills of liaison and consultation are required (see references and section below emphasising the importance of this).
It's worth considering how these concepts relate to other concepts you may use - psychoanalytic, object-relations, behavioural, cognitive, supervision, organisational? What's special about a systems approach - I think it's more a way of thinking and acting in a situation; not a theory - more a frame-work for almost any wise method.
TEAM OF AGENCIES
Catchment Area.
Within the catchment area of a service, the word "team" is used to emphasise how positively you must think about other agencies. The characteristic of being a "team" is "the intention to sort something out". Once that's done and good working practices are established, the set up is more like a "network" where you may not need to see each other much, though you often phone each other. But meetings may of course be necessary. Since they are time and personnel consuming events, it is important that everyone knows how to make them work well.
Administratively, the planning of services needs to create "co-terminus" boundaries for the relevant agencies in the area - you want to "play with the same team" each week. Obviously a small special agency will cover a larger area than the frontline agencies. For example, our CFC team serves the same District as the District Social Work Department, but there are five SWD Area Office areas in that district. The point is that no SWD Area has to deal with two CFC teams. However, the smaller the catchment area the better - make sure your department breaks down into as many district attached (if not based) teams as possible. (This provides a (poor) solution for the common problem of equal professionals having different approaches. Ideally this example of interpersonal conflict should be resolved better, but this resolution at least prevents confusion or undermining within the same district.)
General Agency Links.
Becoming a "team" of agencies requires different kinds of liaison. Organisational links are needed as recommended following all child abuse enquiries. Co-operation is easy to say, but not to do. There is usually open misunderstanding, dislike and conflict between disciplines and agencies, promoted because it is not the cases that go right that get known about by other agencies, only the ones that are going wrong! Initially and occasionally, you need face to face meetings - so that you take enough time to know the person properly, not just as an official on the end of a phone or letter. Where this is for general liaison, the disadvantage may be that the discussion is too abstract; where the meeting is over a case, the disadvantage is that the dynamics and pressure of crisis compromise proper discussion. The aim is to be clear what each agency sees as their job and to get to the state where positive (not defensive) contact occurs when necessary, negotiating respectfully whose case it will be, and so on.
Liaison Over Cases.
But once good relations are established, often telephone and letter liaison is adequate and economic. Again, easily said, but remember how dedicated you may have to be to phone someone successfully. With busy family doctors, paediatricians and phsyicians, the phone call may be the most you can hope for. But where possible and necessary, it is not a waste of time (if someone knows how to make them work) to attend, recommend or carefully arrange inter-agency case conferences, discussion, or consultation, prior to or instead of taking a case on. In taking this approach, there are tough ethical issues in integrating the rights of clients with the needs of inter-agency relations. When does interagency "sheep-dogging" of a multi-agency case become unethical ignorance of client's rights for confidentiality and choice?
Different services and countries need to apply these principles to their own context. What kind of culture, resources, other agencies, laws and so on, influence how you can operate? In England, for example, there is a different system of juvenile justice which is far less appropriate than the Scottish Childrens Hearings. And throughout Britain, co-operation between agencies, while being advocated, is also quite incompatible with the competition being hammered into place through the government's drive to create a "market" for health and other services. You can try to identify what your agency's task is in relation to others. For example, if all the local agencies were a football team, CFC's position I think of as a flexible "sweeper" or "libero". Thus, recent changes in the prescribed tasks on other agencies have meant that CFC has had to develop more resources for the direct family and individual work that others are now limited from doing well.
GOOD BASIC PRACTICE
Broad spectrum of problems and practice. We talk, in medicine especially, as if each of life's problems can be distilled into one diagnostic term, and treated with one prescription. Even if we are working in simple medicine where that is roughly true, there are still many other aspects of professional practice that are so obvious they are taken for granted, even though they may often be missing. When dealing with the unique predicaments of life, it is crazy to talk as if they can all be pinned down and treated with only one therapy, one school of thought, or one special kind of focused strategy. While private practitioners may get away with that, in a welfare state service like CFC, while a family-systems approach is the routine framework, the range of problems and client motivation that we may need to assess and work with cover a very broad spectrum - anything from pericarditis, to sexual abuse and child care issues. There are special skills to be developed (for example, in working with families), but a systems approach should pay as much attention to the surrounding basic skills, and ordinary humanity between workers and with clients. In "Family Therapy: the rest of the picture" FT was shown to be a collection of 90 components, mostly not specific to FT.
But it is not just for your own work setting and clients that "good basic practice" is important. In a field where there can be no defined category of problems selected and no wonder method that cures everything, one of the best contributions to a district's other agencies is to provide an implicit model of good practice that can be seen, used and related to by other agencies, generating (over a period of years) a common high standard of good practice in the district. Again, this is aided by a demystified, egalitarian approach and non-technical language, which was not, but is now becoming more characteristic of Family Therapy.
Basics.
In brief, some of the basics that may not be able to be taken for granted include: personal maturity, grasp of local language and culture, suitable experience and qualification, organising time/ diary/ priorities, setting up appointments, basic interviewing skills, case management and files, phones, letters, ethics; office facilities, protection from intrusion on work, basic support and supervision of work, stable group of colleagues, key-worker per case with attention to holidays and other leave, adequate autonomy of worker, assessment of nature of client motivation, premises, review/follow-up of cases/ feed-back from other agencies about cases.
Less basic elements, more characteristic of Family Therapy methods, include: technology (one way screens and video), a problem-solving/ "systems" way of thinking/framework and aim, special training, knowing the value of conjoint interviews, taking consultation breaks, increasingly using live teams, a systems/ interactional formulation and intervention, research.
Discussion could be about how many components of good basic practice are there in your work setting and in other local agencies? Which could you/they use or improve? For example, there is nothing to prevent you taking a break in your sessions straight away. In the local agency "team" network - how do you think other agency workers "see" or experience your basic practice - for example, through how you write letters, or respond to phone calls?
LIVE TEAM METHODS
Common Sense.
As long as good basic practice and good team relationships exist, we believe that live team methods are worth their weight in gold. You don't need mystifying Family Therapy training, technology or large teams to do it. In fact one colleague is often better. The complexity of the task of conjoint family interviews, interagency and wider systems issues, multi-disciplinary aspects, and the broad range of problems (especially in the peripheries where you cannot specialise and have to do it all), all make live help common sense. It serves many other purposes too - the discharge of any special responsibility of your discipline, audit, morale, training, and informing visitors and managers. Not only does it produce effective work, but it is also economic, preventing unproductive work and so keeping your diary clear of "those" cases. And, of course, it is a great way to be trained. But, teams and live teams can be terrible; if they are, don't use them. And "live teams" don't exist in a vacuum - all sorts of professional and personal things need to be sorted out away from the live sessions with families.
Standard Routine.
We value a standard in-house routine (except when we don't!) within which variety can flourish. The key meeting is the weekly allocation discussion and diary checking meeting which ensures that we are prepared adequately for all the team-family appointments we have. We use a standard 5-part routine of team-family interviews - team pre-meeting discussion (10 minutes including the important meeting and checking out with the family in the waiting room), the first half of the main interview (worker and family talking while observed by team (45 minutes), team consultation break (15 minutes, while family take theirs too, separately), second half (15 minutes), post-meeting team discussion (5 minutes plus).
Case Consultation
We increasingly offer case consultation to workers in other local agencies who are working with family cases (especially social workers). Again a routine is valued, although it is kept informal. One of us is the main worker for the consultation, another sits back as their consultant (taking a consultation break in the room usually). But it is important to get well-prepared beforehand by discussing reports supplied and so on. And we expect the worker's immediate line manager to come to contribute and back up any suggestions. You need to distinguish a consultation to the other worker's work, from a case discussion or case conference (for example, on the way to asking for your active involvement in seeing the family). We always summarise the discussion in a letter to the referrers who came. Letter-sriting in ordinary language, with appropriate copies to agencies involved and often to families, is an important under-valued skill in all our work.
SUMMARY
This paper summarises what have been important elements of developing a child and family mental health service with (originally) minimal resources in the peripheries of excellence. I have described the general work context (geography, services to the district, and the job), the few resources but single task (of service compared with the centres, the community being our "institutional" attachment, de-medicalising and de-mystifying being desirable and necessary), some concepts (cybernetic, problems of living, and a family systems approach, now called systemic practice), the idea of a "team of agencies" or services (working to catchment areas, and with general and case-related liaison and links), all of which leads our service to focus on good basic practice and team and live team methods.
Original August 1991, updated September 1998
FAVOURITE REFERENCES
Adams, P & Mylander, M (1993) Gesundheit! Healing Arts Press: Rochester USA.
Bailey, A (1997) TalkWorks: How to Get More Out of Life Through Better Conversations. BT Forum, British Telecommunications (UK Freefone 0800 800 808; at BT CiB, Freepost (SWB195), BRISTOL BS1 4BR)
Baran, D (1993) From periphery to peripheries of excellence. CONTEXT (Autumn), 16, 20-22
Carpenter, J & Treacher, A (1993) Working together. Chapter 10 (pp204-223) in: Using Family Therapy in the 1990s. Basil Blackwell: London.
Child, N (1987) Who needs an in-patient unit? A family systems perspective. AFT Newsletter, 7, 7-9
Child, N (1989) The myth of hysteria as illness Letter in British Journal of Psychiatry, 155, 865-866.
Child, N (1989) Family therapy: the rest of the picture Journal of Family Therapy, 11, 281-296
Child, N (1991) Quality thinking and a formula they [managers] can't refuse Psychiatric Bulletin of Royal College of Psychiatrists, 15, 476-477.
Child, N. (1992) Finding a philosophy that fits. Letter in Journal of Family Therapy, 14, 225-7
Child N (1994a) Family therapy and professionalism. CONTEXT (Summer), 19, 4-6
Child N (1994b) In the media: A Door to Open or Shut? CONTEXT (Summer), 19, 29-30
Child N (1996a) How true story telling lost its place. CONTEXT (Autumn), 28, 34-37
Child N (1996b) Possessing the key: enchanting work. CONTEXT (December), 29, 14-19
Child, N (1997) Celebrating audience. CONTEXT (December), 34, 14-15
Child, N (1998) Ill-logical thinking in child psychiatry. In Press.
Csikszentmihalyi, M (1992) Flow: The Psychology of Happiness. Rider: London
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Jones, E (1993) Family Systems Therapy: Developments in the Milan-Systemic Therapies. Wiley: Chichester
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White, M (1995) Re-Authoring Lives: Interviews and Essays. Dulwich Centre Publications: Australia
Having done all my training in Edinburgh, Scotland, I have worked for two decades as a Child and Family Psychiatrist in the National Health Service (NHS) sector in Lanarkshire, based in the Motherwell "Child and Family Clinic". The phrase "Peripheries of Excellence" implies that peripheral settings can be as excellent in many ways as the centres are!
What I have to say is mostly obvious and not original. It's really just one type of good community psychiatry. I do not propose it as absolute truth - if a better one suits you, disagree with me and use it. This account was developed for an international WFMH European Regional Council congress in Prague, 1991, on the theme of Family Systems Health. In its workshop format, this material was presented with time for small group discussion in pairs in order to aid understanding, explore similarities, differences, equivalents, applicability to other countries and work setting, etc. There was not time to go into clinical details of work with families. In summary, if you saw us at work, at first you would think it's a lot of routine live team Family Therapy. Much of it is - a mixture of Milan and Robin Skynner. But, for providing a comprehensive Mental Health service, we have to be simpler, broader and more creative, open and flexible. We call it a Family Systems Approach. We might now call ourselves Systemic Practitioners, applying family systems ideas by other helping professions than qualified Family Therapists. We are not a Family Therapy service even if it looks as if we are. There are other reasons for this terminology: we find "therapy" is a mystifying and medical term, and we work with other systems than just families.
GENERAL WORK CONTEXT
Geography:
Lanarkshire lies to the East and South of Glasgow, and 40 minutes drive from Edinburgh - both being "centres". It is a mixture of run-down deprived urban industrial towns, small towns, new towns, and rural areas. I work in a small multi-disciplinary team that serves one of the three districts (each with a population of about 200,000). We share nice premises with one of the other similar small district teams. From 1999, we re-organise in parallel with the local authority re-organisation into North and South Lanarkshire. Two pairs of teams will serve each of these, leaving the team I work in to serve only the urban part of the previous area, population about 150,000.
Services in the District:
Only by 1991 and after years of marathon ups and downs did we pass a "minimal basic" level of staff in our teams. Now each team is composed of social worker, clinical psychologist, nurse therapist, child and adolescent psychotherapist (in ours), and consultant psychiatrist with a secretary and sometimes trainees from each of the disciplines.
Who else serves this district?
Britain is still a welfare state (despite radical cuts and changes set going by Mrs Thatcher in the 1980s); Lanarkshire has deprivation, high unemployment and a traditionally socialist population (including immigrants from E.Europe). There is therefore little private practice or private education. Even the major changes set going by the government to make the welfare system more business-like are not intended to alter the "service for all and free at the point of delivery" approach to health, social and educational services. These are provided by two state authorities (from the NHS in the form of General Practitioners (GPs) and specialist hospitals and services from Lanarkshire Healthcare NHS Trust (as it is now but again to be reorganised by the Labour government to include a stronger involvement of General Practitioners), and from Local Government: Strathclyde Regional Council, which was the largest local authority in Europe, they say, has been disaggregated and (intentionally) disorganised so that North and South Lanarkshire have taken over, splitting and complicating our carefully coterminus team catchment areas in the process. So, also serving our new smaller district, are the following: (collected mainly in local Health Centres) 80 GPs, also known as "family doctors", with Health Visitors and Nurses; 70 social workers in 3 Area Offices + Social Work Day Assessment Unit + other kinds of social services; 17 educational psychologists serving numerous schools which have their own Guidance Teachers on the staff; 1 main District General Hospital (including Paediatrics and a small Hospital Social Work staff who do much of the work we would have to do there if they didn't - eg parasuicide); 1 adult psychiatric hospital (including 6 consultant psychiatrists for the district, adult clinical psychologists, Community Psychiatric Nurses and an adult day hospital etc next door to us, along with CMHTs and Psychotherapy service more recently.
The Job:
Our task is not just to set up our private practice stall until a handful of patients pay you a living - that's easy, and does little for spreading mental health. Nevertheless, in some ways it's not a lot different. Like most British Child and Family Psychiatric services, our core task is to take referrals sent to us. Of about 280 referrals a year, 50% come from GPs, and most of our time is taken up with conjoint family appointments, team screenings and meetings, phoning, letter-writing etc. But our task is actually to provide a comprehensive service to the child and adolescent population in the district, age range 0-18 years plus. This is a mountainous task! Taking the usual rates of defined "psychiatric disturbance", there are in Lanarkshire as a whole, about 6000 children, and 1500 adolescents with significant disorder. If you think of these as members of families, then there are some 20,000 family members involved too. And what about a more positive (salutogenic) approach to support "mental health" in general, not just around "cases"? There is an English phrase about "mountains and molehills" - we're like a mole with a mountain to dig away!
In the workshop, at this point, small group discussion was asked for on these aspects -geography, district character and services, and work task.
FEW RESOURCES BUT ONLY ONE DEMYSTIFIED JOB
Minimal Resources.
Compare our minimal team, the task and the size of the population again. We have no day or in-patient units at our disposal; there are no additional specialist adolescent, psychotherapy or other special services for this age group in the district - we take the whole range of problems. We have a concept we called "the Gatehouse Combination": minimal staff dedicated to respond to "community" well enough to limit and control the need for the more intensive in-patient and day units. We cannot be an "open door" to families, responsive and active in liaison with referring and other helping agencies (which does not mean necessarily travelling to see them). The aim is to be responsive to families and professionals and always sort something satisfactory out. This requires stamina and long-term single-mindedness. But there are benefits of starting with almost no services - we have turned deprivation of resources into freedom to develop a progressive service. In a fresh geographical area, there are no conflicting old style set-ups to take on, and no rival mental health services - there are advantages to totalitarianism!
Which Institutional Needs Take Priority?
Though CFC does have trainees, we are pleased not to have the functions the "centres" have to carry - big departments, in-patient units, being one of many departments within big hospitals, running university courses with constant mainline teaching and training responsibilities, local and national academic and professional committees, research, conferences, extra-mural courses. In my view, these extra organisational demands require my "central" colleague to do six jobs compared with my one job, providing a service. Where my colleague in the "centres" is primarily attached to all those "central" institutional demands, the "peripheral" person is primarily available and attached to client & other agencies - the community is my "institution". In addition, the benefit in a "periphery" is that it is easier to set aside professional identities and barriers so that you can go for what's useful & works instead.
De-medicalise and De-mystify.
Another main strand for us is to de-medicalise. I have argued (see references) against the attempt by child psychiatrists to seem to fit everything that moves into "International Classifications of Diseases! That we know we are working with "multi-factorial" matters means that our field has to be multi-disciplinary and multi-agency. That we know that the key factor in causing disorder is (unique) "predicaments" and "relationships" (particularly family relationships) means that we are not in the realm of biomedical disease. Therefore other labels are valid and perhaps the best ones are those of ordinary language (eg a conduct disorder would be better described as being naughty, or out of adult's control etc). I suggest instead that the doctor/psychiatrist's authority and skill is (notionally) in diagnosing "health" and moving on to understand and help with "problems of living" and "predicaments", again finding that ordinary language is best. Similarly, other disciplines' authority can be recast: social workers can decide when compulsory measures of child-care are not required; the psychologist can say that no special testing or educational or treatment method is needed. Even the word "therapy" we don't use because it is unclear, medical, mystifying and unacceptable to the local culture. But problems are no less serious for being responded to like this - people are so distressed they would prefer that they were bio-medical! So our "mountain" is a shared "mountain", shared with other disciplines and agencies. The field of helping "problems of living" is everyone's and no-one's. 95% of families don't need special help - that's because people and families are usually able to sort their own lives out without the help of any professional. (Perhaps where the "peripheries" allow us to de-medicalise and de-mystify, it is the "centre's" task to do the opposite: to sustain and develop professional mystification! It is the establishment's task to change slowly and only when it is persuaded of anything new. Maybe these are necessary opposite parts of the system!)
Pairs were to discuss their understanding of this and compare what resources they have, the number of jobs per person they're expected to do, the possibilities for de-mystifying?
CONCEPTS
I dislike abstract concepts in general, and my tendency is to do away with any theory. But I realise that I do have theory. Concepts are also what conference attenders and article readers tend to take away and use. And I realised that, in the early years in Lanarkshire, the concepts served me well, providing firm guidelines in a difficult and unsupportive context. But as colleagues came and contributed their own ideas and work, the real thing makes the concepts insignificant and forgettable. This must happen to an architect or town planners' "blueprints" when the house or town is built and populated by real people inhabiting what was originally just an image in the mind or on paper. In the absence of being taught anything suitable in my medical and psychiatric training, my theory had to be imported from outside it. Then, since noone understood it, I had to adapt it too. It came from the (relatively unknown Scottish) philosopher John Macmurray's ideas of "Self as Agent" and "Persons in Relation".
Cybernetic Ideas.
The result is basically a rather cybernetic model that amounts to a simple "systems" theory of "people with tasks and problems, one or more other people with solutions, and "inner persons", all of whom may get into inter- and intra- personal conflict which then becomes a different category of problem itself, presenting in direct or disguised forms, requiring methods of inter- and intra- personal conflict resolution which can be by an enabling process (helping the person to cope with their own problem) or by a "detaching" or "abling" process (one person taking the problem away from the other), but often by a disabling process (enabling being blocked). Simply, problems are solved by integrated solutions and sustained by unintegrated solutions, for example, an individual being "in two minds", or two people/ parents disorganised or in conflict, or two helping workers or agencies in conflict. Of course, some problems are themselves solutions from a systemic viewpoint.
Problems of Living.
On this basis, I link "family problems of living" through the main agencies (serving children) to the multi-disciplinary team of doctor/psychiatrist, social worker and psychologist. Problems of living organise and present in, or "as if" they are in, three main groups - "bad" (social need), "slow" (developmental or educational need), and "ill or mad" (medical or psychiatric need). This mirrors (in our culture in Britain) the three main front-line agencies, each with free access within the welfare state: the social services, schools (backed up by educational psychologists), and general medical practitioners. In our case, provided jointly by the two main authorities (Local Authorities, and Health Boards), the specialist services used by the front-line services finds the three aspects and front-line agencies reflected in the team. Each discipline has a notional responsibility for keeping in contact with their respective front-line agencies, and accounting to their respective employing authorities.
But, as outlined above, each discipline is not primarily trying to increase the power and realm of their own discipline - as they would be in the "centres". They are integrating their different specialist authorities more to diagnose the absence of biomedical disease, the absence of need for special developmental assessment or educational provision, and the absence of need for measures of child care", than to try and label and claim them for their own discipline. Once these concerns are authoritatively (though often not explicitly) put in their place, the field of offering to help work out what the problem may be is addressed. This field of problems belongs to everyone and noone and includes the possibility of other agencies being involved (not just statutory, of course). This then is what can be called "family-systems work", though preferably this common field should have no name, lest it be mystified or thought to be claimed by one sector as opposed to another. Any term that includes the word "therapy" is not appropriate for this reason.
For me, this theory of people and problems leads to an egalitarian, co-operative, multi-disciplinary, and multi-agency, team approach. It is a more accurate conception of the traditional medical language of "psychiatric disorders" being "multifactorial" and requiring "multidisciplinary solutions". The team, while fully aware of the professional task and contract, is firstly people and secondly professionals - the special professional and personal skills and characteristics serve the collective purpose of the person and team.
A number of other more metaphorical images and ideas link to these concepts. For example, the story of the Hare and Tortoise has wide application to how people of all kinds can be enabled or disabled - to what profile to take in organisation and training of Family Therapy, in relating to local agencies, in attitudes to client individuals and families, to team colleagues and trainees.
Family Systems Approach (or Systemic Practice)
Other concepts are more commonly known. A family systems approach is basically human common sense which experience teaches - better than words and conferences! A systems approach considers the individual as a system and sub-system of family (and other groups), the family as system and sub-system of wider systems and (when family functioning "fails" to contain the problem) agencies. The features of the method of work are those most highly developed in the Family Therapy approach - the family system is considered to be the case; one key-worker and key-agency allows the system and work to be integrated and worked with as such where possible. Where multiple agencies are involved, notions like "minimal sufficient network", and skills of liaison and consultation are required (see references and section below emphasising the importance of this).
It's worth considering how these concepts relate to other concepts you may use - psychoanalytic, object-relations, behavioural, cognitive, supervision, organisational? What's special about a systems approach - I think it's more a way of thinking and acting in a situation; not a theory - more a frame-work for almost any wise method.
TEAM OF AGENCIES
Catchment Area.
Within the catchment area of a service, the word "team" is used to emphasise how positively you must think about other agencies. The characteristic of being a "team" is "the intention to sort something out". Once that's done and good working practices are established, the set up is more like a "network" where you may not need to see each other much, though you often phone each other. But meetings may of course be necessary. Since they are time and personnel consuming events, it is important that everyone knows how to make them work well.
Administratively, the planning of services needs to create "co-terminus" boundaries for the relevant agencies in the area - you want to "play with the same team" each week. Obviously a small special agency will cover a larger area than the frontline agencies. For example, our CFC team serves the same District as the District Social Work Department, but there are five SWD Area Office areas in that district. The point is that no SWD Area has to deal with two CFC teams. However, the smaller the catchment area the better - make sure your department breaks down into as many district attached (if not based) teams as possible. (This provides a (poor) solution for the common problem of equal professionals having different approaches. Ideally this example of interpersonal conflict should be resolved better, but this resolution at least prevents confusion or undermining within the same district.)
General Agency Links.
Becoming a "team" of agencies requires different kinds of liaison. Organisational links are needed as recommended following all child abuse enquiries. Co-operation is easy to say, but not to do. There is usually open misunderstanding, dislike and conflict between disciplines and agencies, promoted because it is not the cases that go right that get known about by other agencies, only the ones that are going wrong! Initially and occasionally, you need face to face meetings - so that you take enough time to know the person properly, not just as an official on the end of a phone or letter. Where this is for general liaison, the disadvantage may be that the discussion is too abstract; where the meeting is over a case, the disadvantage is that the dynamics and pressure of crisis compromise proper discussion. The aim is to be clear what each agency sees as their job and to get to the state where positive (not defensive) contact occurs when necessary, negotiating respectfully whose case it will be, and so on.
Liaison Over Cases.
But once good relations are established, often telephone and letter liaison is adequate and economic. Again, easily said, but remember how dedicated you may have to be to phone someone successfully. With busy family doctors, paediatricians and phsyicians, the phone call may be the most you can hope for. But where possible and necessary, it is not a waste of time (if someone knows how to make them work) to attend, recommend or carefully arrange inter-agency case conferences, discussion, or consultation, prior to or instead of taking a case on. In taking this approach, there are tough ethical issues in integrating the rights of clients with the needs of inter-agency relations. When does interagency "sheep-dogging" of a multi-agency case become unethical ignorance of client's rights for confidentiality and choice?
Different services and countries need to apply these principles to their own context. What kind of culture, resources, other agencies, laws and so on, influence how you can operate? In England, for example, there is a different system of juvenile justice which is far less appropriate than the Scottish Childrens Hearings. And throughout Britain, co-operation between agencies, while being advocated, is also quite incompatible with the competition being hammered into place through the government's drive to create a "market" for health and other services. You can try to identify what your agency's task is in relation to others. For example, if all the local agencies were a football team, CFC's position I think of as a flexible "sweeper" or "libero". Thus, recent changes in the prescribed tasks on other agencies have meant that CFC has had to develop more resources for the direct family and individual work that others are now limited from doing well.
GOOD BASIC PRACTICE
Broad spectrum of problems and practice. We talk, in medicine especially, as if each of life's problems can be distilled into one diagnostic term, and treated with one prescription. Even if we are working in simple medicine where that is roughly true, there are still many other aspects of professional practice that are so obvious they are taken for granted, even though they may often be missing. When dealing with the unique predicaments of life, it is crazy to talk as if they can all be pinned down and treated with only one therapy, one school of thought, or one special kind of focused strategy. While private practitioners may get away with that, in a welfare state service like CFC, while a family-systems approach is the routine framework, the range of problems and client motivation that we may need to assess and work with cover a very broad spectrum - anything from pericarditis, to sexual abuse and child care issues. There are special skills to be developed (for example, in working with families), but a systems approach should pay as much attention to the surrounding basic skills, and ordinary humanity between workers and with clients. In "Family Therapy: the rest of the picture" FT was shown to be a collection of 90 components, mostly not specific to FT.
But it is not just for your own work setting and clients that "good basic practice" is important. In a field where there can be no defined category of problems selected and no wonder method that cures everything, one of the best contributions to a district's other agencies is to provide an implicit model of good practice that can be seen, used and related to by other agencies, generating (over a period of years) a common high standard of good practice in the district. Again, this is aided by a demystified, egalitarian approach and non-technical language, which was not, but is now becoming more characteristic of Family Therapy.
Basics.
In brief, some of the basics that may not be able to be taken for granted include: personal maturity, grasp of local language and culture, suitable experience and qualification, organising time/ diary/ priorities, setting up appointments, basic interviewing skills, case management and files, phones, letters, ethics; office facilities, protection from intrusion on work, basic support and supervision of work, stable group of colleagues, key-worker per case with attention to holidays and other leave, adequate autonomy of worker, assessment of nature of client motivation, premises, review/follow-up of cases/ feed-back from other agencies about cases.
Less basic elements, more characteristic of Family Therapy methods, include: technology (one way screens and video), a problem-solving/ "systems" way of thinking/framework and aim, special training, knowing the value of conjoint interviews, taking consultation breaks, increasingly using live teams, a systems/ interactional formulation and intervention, research.
Discussion could be about how many components of good basic practice are there in your work setting and in other local agencies? Which could you/they use or improve? For example, there is nothing to prevent you taking a break in your sessions straight away. In the local agency "team" network - how do you think other agency workers "see" or experience your basic practice - for example, through how you write letters, or respond to phone calls?
LIVE TEAM METHODS
Common Sense.
As long as good basic practice and good team relationships exist, we believe that live team methods are worth their weight in gold. You don't need mystifying Family Therapy training, technology or large teams to do it. In fact one colleague is often better. The complexity of the task of conjoint family interviews, interagency and wider systems issues, multi-disciplinary aspects, and the broad range of problems (especially in the peripheries where you cannot specialise and have to do it all), all make live help common sense. It serves many other purposes too - the discharge of any special responsibility of your discipline, audit, morale, training, and informing visitors and managers. Not only does it produce effective work, but it is also economic, preventing unproductive work and so keeping your diary clear of "those" cases. And, of course, it is a great way to be trained. But, teams and live teams can be terrible; if they are, don't use them. And "live teams" don't exist in a vacuum - all sorts of professional and personal things need to be sorted out away from the live sessions with families.
Standard Routine.
We value a standard in-house routine (except when we don't!) within which variety can flourish. The key meeting is the weekly allocation discussion and diary checking meeting which ensures that we are prepared adequately for all the team-family appointments we have. We use a standard 5-part routine of team-family interviews - team pre-meeting discussion (10 minutes including the important meeting and checking out with the family in the waiting room), the first half of the main interview (worker and family talking while observed by team (45 minutes), team consultation break (15 minutes, while family take theirs too, separately), second half (15 minutes), post-meeting team discussion (5 minutes plus).
Case Consultation
We increasingly offer case consultation to workers in other local agencies who are working with family cases (especially social workers). Again a routine is valued, although it is kept informal. One of us is the main worker for the consultation, another sits back as their consultant (taking a consultation break in the room usually). But it is important to get well-prepared beforehand by discussing reports supplied and so on. And we expect the worker's immediate line manager to come to contribute and back up any suggestions. You need to distinguish a consultation to the other worker's work, from a case discussion or case conference (for example, on the way to asking for your active involvement in seeing the family). We always summarise the discussion in a letter to the referrers who came. Letter-sriting in ordinary language, with appropriate copies to agencies involved and often to families, is an important under-valued skill in all our work.
SUMMARY
This paper summarises what have been important elements of developing a child and family mental health service with (originally) minimal resources in the peripheries of excellence. I have described the general work context (geography, services to the district, and the job), the few resources but single task (of service compared with the centres, the community being our "institutional" attachment, de-medicalising and de-mystifying being desirable and necessary), some concepts (cybernetic, problems of living, and a family systems approach, now called systemic practice), the idea of a "team of agencies" or services (working to catchment areas, and with general and case-related liaison and links), all of which leads our service to focus on good basic practice and team and live team methods.
Original August 1991, updated September 1998
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