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This article was downloaded by: [82.132.210.188] On: 09 November 2011, At: 09:18 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK Journal of Social Work Practice Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/cjsw20 Emotion in crisis: primary and secondary mental health contexts Julie Morton Available online: 22 Feb 2010 To cite this article: Julie Morton (2010): Emotion in crisis: primary and secondary mental health contexts, Journal of Social Work Practice, 24:4, 461-474 To link to this article: http://dx.doi.org/10.1080/02650531003594036 PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: http://www.tandfonline.com/page/terms-and-conditions This article may be used for research, teaching, and private study purposes. 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The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material. Julie Morton EMOTION IN CRISIS: PRIMARY AND SECONDARY MENTAL HEALTH Downloaded by [82.132.210.188] at 09:18 09 November 2011 CONTEXTS The purpose of this paper is to explore the relationship between emotion and the experience of a mental health crisis, in particular how this relationship is understood in crisis resolution services and formal mental health (primary and secondary) services more broadly. The paper presents some findings from a small scale study of a Crisis Resolution/Home Treatment Team (CRT/HT) in the North West of England. The specific findings discussed relate to: (i) the nature of the crises people presented with; (ii) diagnostic category; and (iii) staff perceptions of what they felt had most helped individuals. The analysis of emotion is developed from these findings in this crisis service where practitioners seemed to implicitly understand crisis and emotion relationships even though these were seldom articulated or acknowledged in the practices and procedures intended to assist people in crisis. The paper goes on to develop an analysis of these findings in the context of current service provision and offers a conceptual exploration of the limitations which may be found in the acknowledgement of the relationships between emotion and crisis. The paper suggests that emotional context for an individual is considered differently depending on which parts of the formal mental health services are accessed. Keywords crisis; emotion; mental health services Introduction My interest in emotion arose from a small scale study of a Crisis Resolution Team (CRT) in the North West of England. The study was quantitative in nature and gathered information about who used the service and the types of interventions utilised by practitioners. On completion, I became preoccupied with what I had been unable to capture. In particular, the nature of a crisis and the assumption in the establishment of CRTs that those people experiencing crises would be drawn from the constituency of people deemed to have a diagnosis of severe mental illness. As a specific service, CRTs sit within secondary services so it also seemed important to consider more widely the notion of primary and secondary care. Whilst this article provides a discussion of findings and analysis of these in relation to emotion in crisis teams, this is developed Journal of Social Work Practice Vol. 24, No. 4, December 2010, pp. 461–474 ISSN 0265-0533 print/ISSN 1465-3885 online q 2010 GAPS http://www.tandf.co.uk/journals DOI: 10.1080/02650531003594036 462 JOURNAL OF SOCIAL WORK PRACTICE and placed in the more general context of formal mental health services and offers some preliminary discussion of how emotion is understood and considered in different psychiatric contexts depending upon which part of those services is accessed. Downloaded by [82.132.210.188] at 09:18 09 November 2011 Crisis Resolution Teams — the service setting Crisis Resolution Teams (CRTs) in the United Kingdom, along with other specialist mental health teams (Early Intervention and Assertive Outreach) targeting people with severe mental illness, are firmly embedded in mental health policy [NHS Plan (Department of Health, 2000); National Service Framework for Mental Health (Department of Health, 1999)]. Typically, CRTs offer assessment of individuals ‘in crisis’ usually with Accident & Emergency liaison. CRTs have the dual role of gatekeeping (diverting people from hospital admission) and provision of home treatment [Policy Implementation Guide (Department of Health, 2001)]. Home treatment typically offers a range of practical and therapeutic interventions outside of hospital, and usually in the person’s home. There are, however, difficulties in relation to fidelity to this model and CRTs vary across the United Kingdom both in assessment and Accident & Emergency liaison arrangements and in what home treatment consists of. The majority of studies have looked at CRTs in relation to reduction in admission. For example, admissions following contact with emergency and intervention teams. A recent Audit Office report focused on the efficacy of teams in assessment and diversion from hospital, viewing these as critical functions of the teams (National Audit Office, 2007). CRTs generally do not seem to have delivered services to the intended group of individuals with a severe and/or enduring mental illness and in fact receive a much wider group with both social and psychological crises as well as crises relating to an existing or emerging mental illness. More recent studies show a complex picture with individuals presenting to CRTs with a range of difficulties, some of whom have a diagnosed mental illness whilst others do not. A study of admission decisions following contact with emergency assessment and intervention services (Brooker et al., 2007), for example, indicated that presentations relating to suicide risk were more common than those relating to serious and enduring mental illness. Emotion and crisis Caplan’s (1964) work on preventive psychiatry provided a classic conceptualisation of crisis. This definition and description has been a major influence on subsequent thinking about the nature of crisis in formal mental health settings. Caplan’s view was that individuals maintain a level of emotional homeostasis and are able to use problemsolving abilities to deal with stress. Certain situations may present such a challenge to the individual that s/he is unable to draw on her/his usual coping mechanisms and a crisis reaction occurs. Caplan did not view a crisis reaction as pathology but as a ‘normal response sequence produced by a hazardous external event’ (Cohen et al., 1983). Caplan viewed a crisis as a transition period in which an individual could potentially develop an improved self-concept based on the fact that the crisis had been overcome and they had built up resilience for coping with future emotional crises. In this model, adjustment to the crisis is mediated by the individual’s existing range of coping skills, the perception of the event and the availability of social support. Downloaded by [82.132.210.188] at 09:18 09 November 2011 EMOTION IN CRISIS Caplan’s work continues to be of relevance to service development and delivery in the mental health field in that community mental health teams, with a crisis specialist team or not, would hopefully be assessing the individual’s perception of a crisis, would be working with individuals on coping strategies and would be exploring or mobilising available support networks. Whilst crisis intervention is often described in medical psychiatric literature, ‘crisis’ in itself is not described and is not given a diagnostic category of its own in ICD –10. So although a crisis could be said to occur under any of the mental and behavioural disorders as categorised in the World Health Organisation International Classification of Diseases, Revision 10 (ICD –10), there is no definition of what a crisis is. Literature in this area tends to deal with interventions including therapeutic approaches and management. There is often a distinction made between psychiatric emergencies and psychosocial crises and a preoccupation with the distinction between these in terms of response and intervention. Explorations of the nature of a crisis and what a crisis looks like are rare. Emotion and formal psychiatric care Both the findings regarding the nature of crisis and the response from practitioners in the CRT study led me to want to further explore how we think about emotion in relation to mental health services. The usefulness of looking at crisis is that the experience challenges both service and policy responses as well as our own understanding of mental health and illness. Crises transcend both the usual categorisations of mental disorder (‘common’ and ‘severe’) and the corresponding service delivery split into primary and secondary. How, for example, is the crisis experienced by someone with ‘common’ anxiety different to a crisis experienced by someone with a formal diagnosis of schizophrenia' An individual crisis may take many different forms but systems of classification required by formal mental health services seem at odds with that unique experience. Once accepted into primary or secondary services there is a need for formal structures to intervene by finding an underlying cause which is then classified, rather than a crisis being something more universally experienced. This links to an idea of emotions as being unreasonable or ‘ununderstandable’ and deflects away from the importance of emotions for mental health. In relation to emotion there has been a sociological analysis of emotion and the part it plays in modern life. Williams (2003), for example, has discussed how emotions are central to mental health and illness and refers in passing to the consideration of emotions within the framework of mental illness and ‘irrationality’ as neglecting the role of emotions in the health and well being of individuals and society. This is relevant to the analysis I want to develop, specifically exploring emotion in a service context and the different ways emotion is considered in the traditional service configuration in the UK: the ‘secondary’ and ‘primary’ binary. A study of a CRT The CRT in this study was based in a hospital where psychiatric beds were available. There was close liaison with Accident & Emergency (A&E) so that qualified members 463 Downloaded by [82.132.210.188] at 09:18 09 November 2011 464 JOURNAL OF SOCIAL WORK PRACTICE of the team, usually nurses, assessed every psychiatric emergency which presented. Referrals for assessment also came from General Practitioners and other parts of the mental health service. There was one Approved Social Worker (ASW) in the team who could be called upon if compulsory admission was assessed to be necessary. The study consisted of interviews conducted with a group of staff, including psychiatric nurses, support workers, an occupational therapist, a social worker and a psychiatrist who made up the team. A limitation of the study was that service-users were not interviewed but were the ‘subjects’ of the interviews with staff. The sample was a continuous cohort of 27 individuals who had been accepted by the CRT Home Treatment service. Interviews took place face-to-face with individual staff members. Each interview focused on a particular ‘case’ including sources of referral, the social and medical characteristics of the service-user, presenting risk situations, range and frequency of interventions, staff views about the intervention and conclusions about factors which had contributed to the service-user’s crisis. Interviews were carried out once a service-user had been in the service for two weeks in order for the member of staff to have familiarised her/himself with the case. The study was largely quantitative and used a questionnaire with closed questions. The findings below relating to nature of crisis and staff perceptions have been reported elsewhere along with the other findings in the study (Morton, 2009). However, for the purposes of this article these findings are used to develop an analysis of the role of emotion in crisis and mental health services. The findings on diagnosis are included here as these relate specifically to the discussion of emotion and severity of illness. . . . Diagnosis (closed question with specified categories). The nature of crisis in people presenting to a CRT based on staff perceptions of what contributed to the crises for individuals in a continuous cohort of 27 serviceusers (closed question with specified categories). Staff perceptions of what they did which they felt had most helped users of the service (open question, categories ascribed post research). Composition of the CRT The composition of the team is shown in Table 1. Of the qualified staff, 15 had a health background, one with a social care background. Of the unqualified staff, six were from a social care background and one from health. On establishing the team, nurses were drawn from hospital and two were previously A&E Liaison Nurses. The (Residential Social Worker) support workers had previously been part of the social services mental health network in the community and therefore were familiar with community resources and providing care to people in their own homes. Findings Diagnosis in the cohort Where diagnosis was known, it was specified and Table 2 shows a spectrum of mental health difficulties. The largest single category here is ‘not known’ and (if each of the EMOTION IN CRISIS TABLE 1 Composition of team † Acting Team Leader † 3 G Grade Special Nurse Practitioner (1 vacant post and 1 was Acting Team Leader) † 7 F Grade Nurse Practitioner † 1 Registered Mental Nurse E Grade † 1 B Grade (Health) Support Worker † Occupational Therapist † Approved Social Worker [a social worker in the UK who has undergone additional training in order to carry out assessments for formal admission under the Mental Health Act 1983, recently replaced by the Approved Mental Health Professional (AMPH) following the Mental Health Act, 2007] Downloaded by [82.132.210.188] at 09:18 09 November 2011 † 6 Support Workers (residential social worker grade) † Staff Grade Psychiatrist † Team Leader vacant post † G Grade Nurse vacant post † ASW vacant post † Psychologist (access sessions only) depression categories are taken together) a diagnosis of depression constitutes the second largest group. Of the two cases of post-traumatic stress disorder, this was linked specifically to childhood and early adult experiences of sexual abuse. Two of the subjects were refugees, one of whom had a diagnosis of PTSD which as explained above was linked to disclosure of childhood experiences of abuse. The other refugee had a psychotic illness which was assumed to be long-standing. The range of diagnoses is illustrative of the complexity of cases that the CRT worked with. In the interview schedule a diagnosis that had been made by the CRT was recorded as the diagnosis. In other words, diagnosis was recent and might only have been made since entry into the service. This means that the number of people who had no TABLE 2 Diagnosis Frequency Schizophrenia 3 Bi-polar affective disorder 2 Obsessive Compulsive Disorder (OCD) 2 Post-Traumatic Stress Disorder (PTSD) 2 Borderline personality disorder 1 Depression 5 Depression with anxiety 2 Depression with alcohol 1 Not known 9 Total 27 465 466 JOURNAL OF SOCIAL WORK PRACTICE diagnosis at all when they presented for assessment was greater than that indicated above in the ‘not known’ category. Factors contributing to crisis Interviewees were asked what in their view had contributed to each crisis experienced. This was a retrospective question and was asked of interviewees of the 27 cases when they had had the opportunity to familiarise themselves with each case (see Table 3). . Downloaded by [82.132.210.188] at 09:18 09 November 2011 . . ‘Major’ contribution category. Coping difficulties were viewed most frequently as contributing to crisis and the difficulties people were coping with seemed to be far ranging. ‘Some’ contribution category. It was clear that some individuals were experiencing a relapse of an existing illness but this is a partial picture as this is most frequently seen as having ‘some’ (15 cases) rather than a ‘major’ contribution (three cases). ‘None’ contribution category. Staff, from both health and social care backgrounds, were definite that most cases did not feature a new episode of a mental illness. It seems there may have been reluctance to attribute the complex set of difficulties experienced in this constituency to a diagnostic category alone. Similarly, although 15 people were identified as having a relapse of a mental illness, staff did not view medication (non-adherence) as a contributing factor. Chronic social problems, although identified 13 times as having a major or partial role in the crisis, are also definitely ruled out in 14 cases. This set of findings, which appear conflictual and contradictory, is difficult to make sense of. What they suggest is that the individual experience of an emotional crisis is multi-layered and complex. In addition, the findings may indicate that making sense of crises for practitioners is dynamic and the inter-relationships between the lived experience of a crisis and the ‘making sense’ of a crisis for services are also complex. Staff perceptions of what helped' Following each staff interview (on completion of the study questionnaire) interviewees were asked the open question ‘what did you do that you felt most helped'’. TABLE 3 Factors contributing to crisis Major Contributing factor Major life event Some No Number contribution contribution contribution of cases 27 7 8 12 11 13 3 27 Episode of a new mental illness 2 4 21 27 Relapse of existing mental illness 3 15 9 27 Medication non-adherence 5 6 16 27 Chronic social problems 4 9 14 27 Drug/alcohol misuse 3 1 23 27 Coping difficulties Downloaded by [82.132.210.188] at 09:18 09 November 2011 EMOTION IN CRISIS The elements identified by interviewees are presented in detail elsewhere (Morton, 2009). However, what was significant for me was that practitioners across health and social care backgrounds overwhelmingly identified ‘emotional support’ or ‘just being there’ in their responses as the most significant thing they had done to help the person in crisis. This was identified for 16 of the 27 cases. No other intervention or element was identified as frequently. So although there was a formal care plan in existence with a range of interventions mostly concerned with the monitoring of mental state, team members identified something other than those interventions as most helpful. For practitioners now so familiar with the formalised listing of interventions, the more nebulous and difficult to quantify on care plans was what they felt had been helpful. The constancy of the individual for the person in crisis and the ‘in the moment’ human support seemed to be what practitioners were describing. In other words, what is left out of the technical, regulated and risk driven lists of interventions captured on care plans may be (the rarely acknowledged) emotional engagement with service-users in crisis. Discussion Diagnosis and what constitutes a ‘mental health crisis’' The findings from the study showed that though aimed at those people with a severe illness, this CRT dealt with a constituency of people presenting with wide-ranging difficulties who were experiencing a mental health crisis but could not all be described as having a formal mental illness. In the majority of cases diagnosis was not known and the spectrum of mental health problems spread across the usual categorisations of ‘common’ and ‘severe’. There was seldom one major life event which had tipped people into crisis. Nor were crises a result of ‘poor coping ability’ but rather coping capabilities which had been overloaded resulting in the person seeking or being referred for help. The impression given by staff during interviews was that individuals could no longer contain a range of feelings (associated with such difficulties as loss, relationship difficulties, trauma, seeking refugee status and social-related problems) and emotions spilled over into something they sought help with. The experiences people had were significant but none could be described as solely connected to mental illness or relapse even where there was a previous formal diagnosis. In this CRT, diagnosis was made by the team if there was not a pre-existing diagnosis. The issue of who makes diagnoses generally and how diagnoses are arrived at is complex. It is evident that for recording and audit purposes, a person’s distress has to be categorised in some way. However, for individuals in crisis (and their carers) though the specifics of diagnosis may not be important, the medicalisation of the personal catastrophe experienced may well be desirable. Jones (2002) discusses this in his analysis of families’ experiences of mental illness and comments that the medicalisation of mental distress is a response to deep cultural needs which exist in all of us rather than solely the professional need of psychiatrists to pathologise distress. Some existing literature stresses the importance of the context of a mental health crisis, whether illness related or not. Bridgett and Polak (2003), for example, highlight how decisions to admit a patient to hospital in acute mental distress are made in 467 468 JOURNAL OF SOCIAL WORK PRACTICE Downloaded by [82.132.210.188] at 09:18 09 November 2011 relation to medical need, when there may have been crucial social factors which precipitated the crisis. These social factors may be ignored until the time of discharge. Crisis resolution through home treatment provides the opportunity for professionals to work with an individual in crisis ‘in situ’ with the possibility of the whole situation (medical and social) being taken into account. One criticism of some of the current CRT models adopted might be therefore that they simply present a shift of medically focused care from hospital into the community without expanding the range of interventions on offer. Given the broad spectrum of difficulties people present with in a crisis, it seems important that community services provide alternatives not just to asylum but to the methods inherent in the medical model (Mezzina & Vidoni, 1995). This would mean addressing psychological and emotional issues as well as social experiences. Practice, practitioners and emotion In this study, practitioners across health and social care backgrounds overwhelmingly identified ‘emotional support’ or just ‘being there’ as the most significant thing they had done to help the person in crisis. This was important because regardless of what crisis the person had experienced or what category of disorder they were deemed to have, staff across disciplines concurred. There appeared to be a tacit understanding that emotions and feelings were part of service-users’ crises even though emotional support was not a named intervention or part of any formal treatment plan, plans which are increasingly technical in attempting to quantify and ‘audit’ interventions. Gunaratnam and Lewis (2001) describe a fundamental contradiction in social welfare which deals with and intervenes in the emotional lives of users whereas its systems and practices privilege rationality over emotion. Interventions in the mental health field attempt to rationalise emotions and restore equilibrium in either emotional or thought disorders. Practitioners in the study when asked the question about what was significant about their helping had spoken intuitively in their responses and allowed emotion in. Emotion seemed to me from discussions with the staff in the team to be at some level an implicit part of both the prior negotiations about admission to services and of the intervention to assist in a crisis. What my research showed up was that opportunities for staff to explore this psychological landscape were absent; indeed my study had also omitted this apart from this one open question about how staff felt they had helped. Morrison (2007), writing about social work, has described the role of emotions in engagement, assessment and decision making: ‘Thinking devoid of emotional knowledge is as problematic as emotion devoid of thought’ (p. 256). It is important to see that practitioners are also expected to perform and shape their practice without a space acknowledging or considering the meaning of emotions for the service-users or themselves. Taylor and White (2001) have exposed the limitations for social work of a reliance on technical-procedural approaches in service provision. For practitioners in mental health, interventions to help in both primary and secondary sectors of mental health services are expected to utilise interventions which have an evidence base. In fact, practitioners, in order to make sense of the complexities of practice, do use intuition and ‘feel’ their way around cases. For mental health nurses there are similar constraints. Phillips (2006) describes the unique role mental health nurses have in being with patients creating the base for Downloaded by [82.132.210.188] at 09:18 09 November 2011 EMOTION IN CRISIS a therapeutic relationship which enables feelings and emotions to be explored and contained. However, the current emphasis on action plans and outcomes, risk and prevention, are all factors which reduce ‘the quality time nurses spend with patients and focus very much on doing’ (p. 176). Given the arena in which decisions about admission to CRTs are made (frequently chaotic and emotionally charged A&E departments) and the emotional state of individuals seeking help, further exploration of how emotions play a role, both for the individuals involved and practitioners in the context of a mental health crisis, is needed. Whilst it would be wrong to infer and generalise from this study, it is worthwhile exploring more conceptually the role of emotion in formal secondary mental health services (within which CRTs sit) and the primary care services which are usually the first point of contact for people experiencing difficulties in relation to their mental health. Emotion in formal psychiatric services The current configuration of mental health services in the UK is split into primary care services aimed at those who are considered as having ‘common’ mental health problems such as depression or anxiety (mostly dealt with at General Practice or primary level) and ‘secondary’ specialised (psychiatric) services where individuals are deemed to have more serious mental health problems, often referred to in policy and service documents as ‘severe’ or ‘severe and enduring’. Usually the diagnosis of a mental illness is the passport to entry to secondary services and excludes the group of people who are in contact with the primary care services seeking help with mental health problems (Firth et al., 2004). The ‘emotion’ paradox in this dichotomised service configuration is that when helping with common mental health problems, the emotional content of disorders is viewed as integral to the problems being experienced, in that feelings and emotions are part and parcel of these conditions. This is apparent in both lay and professional understandings of these conditions. In the secondary services category however, for those with severe or more serious mental disorders, consideration of emotion (either in terms of the individual experience of the illness or as a component of the illness) is often avoided. This dichotomy in services is often unhelpful in practice. It can be challenged so that severity is linked with the experience of mental health and level of distress rather than associated with diagnosis. Faced with the range of problems referred to CRTs, in practice it is severity experienced by the individual (not diagnosis and chronicity) which has resulted in acceptance into the service. These decisions are also influenced by prevailing discourses of risk and risk management. There is evidence that some local practices are changing in response to service-user pressure and offering day services for example on a self-referral basis rather than exclusion on the basis of diagnosis and the subsequent link to primary or secondary care distinction. The language of practice is problematic in itself as generally when we talk about ‘mental health’ in service terms we are actually discussing mental ill health or illness. (Anecdotally, in mental health practice settings such as day centres, day hospitals the phrase ‘mental health’ is often used as a pejorative term by service-users which exposes 469 Downloaded by [82.132.210.188] at 09:18 09 November 2011 470 JOURNAL OF SOCIAL WORK PRACTICE the erroneous use of the phrase in policy documents and in service provision.) Vassilev and Pilgrim (2007) have referred to this as a ‘semantic paradox’ in which mental health actually refers to the clinical and legal ‘management’, when required, of those people deemed to be mentally ill. In relation to a mental health crisis, formalising language prevents a wider consideration of what we actually mean by mental ‘health’, ‘illness’ and ‘crisis’ and most definitely leaves out the emotional content of these states. In addition, emotion and emotions are, I think, considered differently depending upon which part of the mental health system is accessed. In primary care, there is usually frank acknowledgement of ‘emotional’ problems with, for example, anxiety and depression, whilst in contrast, in secondary services, there is an avoidance of emotional talk when it comes to mental illnesses such as schizophrenia or bi-polar disorder. Further tensions exist in practice in that particularly with regard to setting criteria for service entry and limiting access to services, the two groups (primary and secondary) operate as though they are oppositional. There is often a hierarchy with professionals working with severe and enduring mental illness viewing this as having a higher status or more importance than work with the greater number of people who experience ‘common mental health problems’. This may be linked to the associations of severe mental illness with risk and the centrality of risk assessment in secondary care. However, primary care services also deal with a wide range of mental health difficulties which may involve levels of risk which are as significant as those found in service-users of secondary services. The following outlines some preliminary considerations of emotion in the primary and secondary care sectors. Emotion and primary care Shaw (2008) refers to the medicalisation of everyday life allowing people to make sense of and claim socially sanctioned recognition for their predicaments. He highlights the increasing number of diagnoses in medicine to encompass all sorts of situations which often are absent of symptoms, giving ME, attention deficit disorder and post-traumatic stress disorder as examples. Williams (2003, p. 146) also comments on how the increase of emotional disorders across the developed world has to be seen in the context of ‘diagnostic bracket creep’. As well as an increase in diagnostic categories, there is a corresponding extension of existing categories such as depression worldwide. These are diagnostic categories (more related to those ‘common’ mental health problems) which are usually acknowledged as having an emotional component — anxiety, depression, post-traumatic stress disorder — by lay people and professionals. The types of experience and distress associated with the expansion of existing categories and proliferation of new conditions generally find their way into the primary care services sector and present a challenge for those services. Although emotions are acknowledged, the responses to emotions here are often pathologising and technical. It is Cognitive Behavioural Therapy (CBT) which is highlighted as being most significant in the Department of Health’s stated commitment to improving access to therapies (CSIP Choice and Access Team, 2008) and this could be described as an intervention which attempts to level out emotions by the promotion of rational thought(s) rather than engagement with feelings. EMOTION IN CRISIS Downloaded by [82.132.210.188] at 09:18 09 November 2011 In everyday life it now seems legitimate to talk about ‘mental health’ and associated emotions — stress and anxiety, general dissatisfaction with our lives. We are more than content to claim our own marker on the mental health continuum, to talk about our ever changing emotional states but we are unlikely to identify ourselves with those people whose mental ill-health is incomprehensible to us. The commonly held notions of emotional imbalance (‘stressed out’, ‘anxious’, ‘low’), so useful to us in our daily lives, do not give us insights into those people with ‘serious’ mental health issues who are deemed to require services more specialised than those offered in primary care and who need to be seen by psychiatrists. Our lay judgments about mental illness allow some emotions to be framed as understandable and reasonable, whilst viewing other forms of illness as beyond our understanding. Emotion and secondary care While for common mental health problems there is an acknowledgement of emotion, for people in secondary services with a diagnosis of ‘severe’ illness there is often reluctance to engage with individuals about feelings for fear it may talk up problems making people even less rational than they are already. Parker et al. (1995, p. 48) point out that patients with a diagnosis of schizophrenia, for example, are ‘categorized as having symptoms beyond the world of normal human discourse or at least the “talking cure”’. Service-users who gain entry into secondary care usually have a diagnosed formal mental illness such as schizophrenia, bi-polar disorder or the more severe forms of depression and these are classified as thought (rather than emotional) disorders. Classification and diagnosis involves the construction of particular aspects of the individual who has been diagnosed (Manning, 2001). A set of representations are then seen to be part of the individual and characteristic of the illness. Once diagnosed, severe mental illness symptoms are viewed as being amenable to particular approaches, these in turn legitimised by dominant knowledge and understandings. In the case of schizophrenia, these include pharmaceutical approaches and a whole range of other interventions designed to meet needs. One area where emotion is acknowledged for this group of people is in the highly researched concept of High Expressed Emotion (EE) and its associated interventions. ‘High EE’ generally describes the over involved or critical communication experienced by people with schizophrenia (although this has been extended to a range of other disorders) in the context in which s/he lives. The communications of the individual and her/his family are scrutinised and advice offered by therapists about how communication could be improved with the aim of reducing relapse and symptoms. These interventions do not leave room for a lay discussion of feelings or emotions. (In practice there are few occasions when the impact of a diagnosis of schizophrenia say is discussed with the patient diagnosed, even though the consequences of such a diagnosis might be discussed in quite emotional ways with colleagues in separate spaces away from the patient.) The role of emotions, individual feelings about symptoms for example, is avoided or ignored in the emphasis on symptom management. Emotion is considered in people with a diagnosis of severe mental illness narrowly. In the case of EE, interventions are grounded on a particular view of the diagnosed person and their living context, ‘technological’ interventions by skilled psychologists are then offered, their efficacy 471 472 JOURNAL OF SOCIAL WORK PRACTICE testified by randomised controlled trials and, importantly in the context of current service drivers, interventions are linked to risk management and relapse prevention. An exception to this approach can be found in the Hearing Voices networks, inspired by the work of Romme and Escher (1993), which explore the content of auditory hallucinations and the impact of the experience of voices on the individual. Downloaded by [82.132.210.188] at 09:18 09 November 2011 Conclusion I have used three findings from a small study of a service response to mental distress as the starting point for this paper. Two of the findings (the nature of a mental health crisis and staff responses to individual distress) are not generalisable in terms of service provision but have prompted me to begin an analysis of mental health, crisis and emotion. I have concentrated on the notion of a ‘mental health crisis’ because it forces us to question the parameters of emotion. It is during a crisis when most people would describe emotions as being un-containable, with these emotions being linked to irrationality or unreasonableness and/or a failing of reason and which brings them into contact with mental health services. Emotional crises do not discriminate and can be experienced by any of us whether we have a diagnosed disorder or not. Specifically, the nature of mental health crises which cut across diagnostic categories and which seem to defy classification into primary or secondary service boundaries is interesting in that it exposes the limitations of current service splits. A broader frame of analysis is important in the examination of what constitutes acceptable and unacceptable emotion in our lives and the reluctance of services to countenance emotions and feelings when intervening in the lives of pathologised and formally diagnosed ‘patients’ in secondary care. Finally, a wider consideration of the relationship between emotion, and reason and mental health and how this is manifested differently in each of the formal sectors may be helpful in thinking about the limitations of the current delivery of mental health services providing pointers for how to conceptualise mental health in alternative ways to the current prevailing discourses which influence provision. For an individual experiencing a crisis in their emotional life, that experience, which is referred to in lay terms as a ‘breakdown’ or ‘nervous breakdown’, is felt as an immediate experience where emotions are difficult to contain. Whatever category individuals are put into is largely irrelevant; what is relevant is what happens next whether in services or outside of them. The range of crises found in psychiatric emergencies presents particular challenges to professionals and yet there is little focus on how professionals make sense of a mental health crisis once accepted into the CRT for home treatment. Does engagement with the individual’s perceptions of the crisis take place' How are the social factors involved negotiated' There is also a gap in the research exploring the crucial phase before admission which is where judgments about entry are made. Practitioners from both social and health backgrounds are constantly making judgments which influence decisions about whether individuals experiencing a crisis will become ‘patients’ and users of services. This area of what constitutes a mental health crisis, what brings people to the point of seeking help, what is considered to be a situation in need of intervention is one with relevance to all practitioners negotiating the interconnections EMOTION IN CRISIS between the (perceived) separate worlds of steady emotional states on the one hand and emotional emergencies and crises on the other. Downloaded by [82.132.210.188] at 09:18 09 November 2011 References Bridgett, C. & Polak, P. (2003) ‘Social systems intervention and crisis resolution. Part 1: assessment’, Advances in Psychiatric Treatment, vol. 9, pp. 424 – 431. Brooker, C., Ricketts, T., Bennet, S. & Lemme, F. 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(2004) ‘Non-statutory mental health social work in primary care: a chance for renewal'’, British Journal of Social Work, vol. 34, pp. 145 – 163. Gunaratnam, Y. & Lewis, G. (2001) ‘Racialising emotional labour and emotionalising racialised labour: anger, fear and shame in social welfare’, Journal of Social Work Practice, vol. 15, pp. 131 – 148. Jones, D. W. (2002) Myths, Madness and the Family: The Impact of Mental Illness on Families, Palgrave, Basingstoke. Manning, N. (2001) ‘Psychiatric diagnosis under conditions of uncertainty: personality disorder, science and professional legitimacy’, in Rethinking the Sociology of Mental Health, ed. J. Busfield, Blackwell, Oxford. Mezzina, R. & Vidoni, D. (1995) ‘Beyond the mental hospital: crisis intervention and continuity of care in Trieste. A four year follow-up study in a community mental health centre’, Journal of Social Psychology, vol. 41, pp. 1– 20. Morrison, T. (2007) ‘Emotional intelligence, emotion and social work: context, characteristics, complications and contribution’, British Journal of Social Work, vol. 37, pp. 245 – 263. Morton, J. (2009) ‘Crisis resolution: a service response to mental distress’, Practice: Social Work in Action, vol. 21, pp. 143 – 158. National Audit Office (2007) Helping People through Mental Health Crisis: The Role of Crisis Resolution and Home Treatment Services, National Audit Office, London. Parker, I. et al. (1995) Deconstructing Psychopathology, Sage, London. Phillips, L. (2006) Mental Illness and the Body, Routledge, Oxford. Romme, M. & Escher, S. (1993) Accepting Voices, MIND, London. Shaw, I. (2008) ‘Society and mental health: the place of religion’, Mental Health Review Journal, vol. 13, no. 1, pp. 4 – 7. 473 474 JOURNAL OF SOCIAL WORK PRACTICE Taylor, C. & White, S. (2001) ‘Knowledge, truth and reflexivity; the problem of judgement in social work’, Journal of Social Work, vol. 1, no. 1, pp. 37– 59. Vassilev, A. & Pilgrim, D. (2007) ‘Risk, trust and the myth of mental health services’, The Journal of Mental Health, vol. 16, pp. 347 – 357. Williams, S. J. (2003) Medicine and the Body, Sage, London. World Health Organisation. International Classification of Diseases. Version 10 (ICD– 10). Downloaded by [82.132.210.188] at 09:18 09 November 2011 Julie Morton is a lecturer in Social Work at the University of Salford. Address: Social Work Directorate, School of Social Work, Psychology and Public Health, University of Salford, UK. [email: j.w.morton@salford.ac.uk]