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.
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
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.
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?
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
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
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
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
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
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