Egalitarianism
ETHEL Field
M.
M.D.
M.
HUBER,
R.N.,
M.S.N.
Representative
Accreditation
Council
Joint Commission Chicago, Illinois
ofPsychlatric
on Accreditation
Facilities of Hospitals
Editor’s Note: Must experiments in role-blurring or responsibility-sharing necessarily end in failure2 Under what conditions might the concept work? We asked two professionals with more positive experience in responsibility-sharing to comment on the preceding paper. #{149}Ms.Doyle’s paper is a positive contribution to the literature. She describes one organization’s experiment in applying the concepts of egalitarianism and roleblurring, and discusses the problems that were created and the solutions that were chosen. The paper highlights the mental health professionals’ mood in the sixties, their revolt against the evils of the bureaucracies, and their basic disenchantment with the territorial imperatives imposed at that timeby the professionalism of the various clinical disciplines. The oppressive effects of the bureaucracies of institutions and the fragmentation of treatment engendered by professional turfs worked to the ultimate disadvantage of the patients. Individuals in mental health hastened to enter a brave new world where old wrongs would be made right, rigidities would be eliminated, chronicity would be vanquished, and all patients and their caregivers would be happy. Instead, professionals became immobilized by freedom from structure, doing one’s own thing became an end in itself, and services to patients suffered. Agencies sought remedies. Some returned to more traditional patterns of staff and program organization. Others began searches that led to a redefinition of concepts and terms, distinguishing outcomes from processes of treatment. mailing
Dr. Bonn’s 80123.
She
Center
in Denver,
formerly
address was
and
Ms.
is 6636 director
West Glasgow, Littleton, Colorado of the Fort Logan Mental Health
Huber formerly was director of
nursing
the center.
526
HOSPITAL
In reading Ms. Doyle’s paper, we were impressed again with how unsatisfactory the term role-blurring is. Blurring connotes indistinctness, indefiniteness, and lack of clarity. In our experience, recognition of the flaws in the term role-blurring led to its restatement as role-expansion. We took role-expansion to mean a clear, preplanned addition to the functions of an individual staff member, based on training and personal qualities, leading to the staff member’s maximum usefulness to the patient. Thus our programs would prevent needless fragmentation of the patient’s treatment and life. Such an approach, we realized, would lead to overlapping of roles for various clinical disciplines. The overlapping couldbe used to the patient’s advantage, however, by having multiple kinds of individuals available to the patients rather than rigidly selected members of one discipline alone. We experienced both the negative and the positive aspects of egalitarianism. Ms. Doyle has documented many of the negatives. The positive aspects we wish to highlight include each staff member’s accountability for his work and actions to those responsible for the program, the value of each staff member’s skills and activities to the program, and the importance of each staff member’s input to the treatment planning and problem-solving process. Perhaps that is a limited application of the concept of egalitarianism, but we have found it useful, workable, and warranted by the facts of organizational life. We found it a necessary tool in combating the associated denigration of skills and real competence, the corollary mindless espousal of ‘everybody is equal,’ and the related denial of the fact that staff need to be learners if they are to function effectively in our field. Too often, the discounting of the relative merits of one treatment activity when compared with another has led to everyone’s wanting to be therapists or psychotherapists rather than everyone’s being therapeutic in using the relevant skills acquired through training in each discipline. A demonstration of fuzzy thinking, as described in Ms. Doyle’s paper, was the mental health professionals’ confusion of the indispensable processes of management with the rigidities and obstructionism of the bureaucratic system, which we all denounced liberally. ‘
Representative
HELEN Field
BONN,
in a Mental Health Center: A Commentary
& COMMUNITY
PSYCHIATRY
at
‘
‘
Still another demonstration of fuzzy thinking was the idea that using power is inherently evil. What we really meant was abusing power, not using power. Thus fuzzy thinking, combined with role-blurring, contributed to the chaos Ms. Doyle described. For years the health field, including mental health, has discounted administration and management as second-rate activities, whether at the front-line treatment unit level or at middle or top management levels of the treatment organization. Thus the health field has tended to ignore the body of knowledge available to guide the development of health service organizations. As one consequence, organizational experiments such as the one described by Ms. Doyle continue to be carried out, to the detriment of all concerned-especially to the patients or clients receiving the services compromised by organizational ineptitude. An essential feature of effective organization and
management of health service delivery is what we and others call organizational preventive maintenance, which is analogous to the preventive maintenance of equipment and machinery. Such built-in organizational preventive maintenance allows for systematic input of every staff member’s contributions of relevant information and skills, aimed at the early detection of trends and problems before crises occur. Problem-solving in a crisis-oriented situation is likely to be a less rational and a more emotional process that is ultimately dysfunctional for all concerned. We suggest that Ms. Doyle’s mental health center staff were beginning to achieve the kind of control of their program afforded by preventive maintenance approaches when the tide turned. We commend Ms. Doyle for writing about an all-toocommon experience. Perhaps readers will learn from this experience and from other material in the literature before embarking on similar, ill-fated ventures.tm
Defi n ing the Differences Between Crisis Intervention and Short-Term Therapy R. STUART, PH.D. Clinical Psychologist KEMSEY J. MACKEY, A.C.S.W. Coordinator, Outpatient Department St. Clare’s Hospital Mental Health Denville, New Jersey MARIAN
Center
Using the model of “person plus stress yields reaction,” the authors discuss the differences between crisis intervention and short-term treatment, including psychiatric emergencies. In emergency treatment the central focus is on the reaction, or symptoms, while in crisis intervention the emphasis is on the stress and its quick resolution. In short-term treatment the focus is on the person and exploration of behavior patterns and feelings. The authors believe that the number of crisis cases handled by a therapist must be limited because of their exhausting
nature.
UThe proliferation in the past decade
The authors’ address Health Center, St. Jersey 07834.
of community mental has made psychiatric
is Outpatient
Clare’s
Hospital,
Department,
Pocono
health centers services more
Community
Road,
Denville,
Mental
New
available to the general public. Many of the centers provide crisis intervention and short-term psychotherapy without a clear understanding of the differences between the two modalities. The differences need to be delineated in order to facilitate more effective treatment. The term crisis intervention suggests that treatment is provided at a time when a patient or family is experiencing a particular crisis. A crisis is usually thought of as an emergency of some sort or a situation of acute stress. It is a time when a great deal of change is being experienced or perceived by the patient, who feels incapable of coping without help. Short-term therapy has been described in the literature as brief or time-limited therapy, ranging from one session up to two years of treatment. One way to apply those concepts is through the use of a model that provides direction for clinical understanding of the patient and his presenting problem. The model assumes that person plus stress yields reaction. Person includes everything the patient presents about himself-demographic data, family background, previous coping mechanisms, developmental history, value systems, and beliefs. Stress is the situation that the person is experiencing. Reaction represents the re-
VOLUME
28
NUMBER
7 JULY
1977
527
ETHEL Field
M.
M.D.
M.
HUBER,
R.N.,
M.S.N.
Representative
Accreditation
Council
Joint Commission Chicago, Illinois
ofPsychlatric
on Accreditation
Facilities of Hospitals
Editor’s Note: Must experiments in role-blurring or responsibility-sharing necessarily end in failure2 Under what conditions might the concept work? We asked two professionals with more positive experience in responsibility-sharing to comment on the preceding paper. #{149}Ms.Doyle’s paper is a positive contribution to the literature. She describes one organization’s experiment in applying the concepts of egalitarianism and roleblurring, and discusses the problems that were created and the solutions that were chosen. The paper highlights the mental health professionals’ mood in the sixties, their revolt against the evils of the bureaucracies, and their basic disenchantment with the territorial imperatives imposed at that timeby the professionalism of the various clinical disciplines. The oppressive effects of the bureaucracies of institutions and the fragmentation of treatment engendered by professional turfs worked to the ultimate disadvantage of the patients. Individuals in mental health hastened to enter a brave new world where old wrongs would be made right, rigidities would be eliminated, chronicity would be vanquished, and all patients and their caregivers would be happy. Instead, professionals became immobilized by freedom from structure, doing one’s own thing became an end in itself, and services to patients suffered. Agencies sought remedies. Some returned to more traditional patterns of staff and program organization. Others began searches that led to a redefinition of concepts and terms, distinguishing outcomes from processes of treatment. mailing
Dr. Bonn’s 80123.
She
Center
in Denver,
formerly
address was
and
Ms.
is 6636 director
West Glasgow, Littleton, Colorado of the Fort Logan Mental Health
Huber formerly was director of
nursing
the center.
526
HOSPITAL
In reading Ms. Doyle’s paper, we were impressed again with how unsatisfactory the term role-blurring is. Blurring connotes indistinctness, indefiniteness, and lack of clarity. In our experience, recognition of the flaws in the term role-blurring led to its restatement as role-expansion. We took role-expansion to mean a clear, preplanned addition to the functions of an individual staff member, based on training and personal qualities, leading to the staff member’s maximum usefulness to the patient. Thus our programs would prevent needless fragmentation of the patient’s treatment and life. Such an approach, we realized, would lead to overlapping of roles for various clinical disciplines. The overlapping couldbe used to the patient’s advantage, however, by having multiple kinds of individuals available to the patients rather than rigidly selected members of one discipline alone. We experienced both the negative and the positive aspects of egalitarianism. Ms. Doyle has documented many of the negatives. The positive aspects we wish to highlight include each staff member’s accountability for his work and actions to those responsible for the program, the value of each staff member’s skills and activities to the program, and the importance of each staff member’s input to the treatment planning and problem-solving process. Perhaps that is a limited application of the concept of egalitarianism, but we have found it useful, workable, and warranted by the facts of organizational life. We found it a necessary tool in combating the associated denigration of skills and real competence, the corollary mindless espousal of ‘everybody is equal,’ and the related denial of the fact that staff need to be learners if they are to function effectively in our field. Too often, the discounting of the relative merits of one treatment activity when compared with another has led to everyone’s wanting to be therapists or psychotherapists rather than everyone’s being therapeutic in using the relevant skills acquired through training in each discipline. A demonstration of fuzzy thinking, as described in Ms. Doyle’s paper, was the mental health professionals’ confusion of the indispensable processes of management with the rigidities and obstructionism of the bureaucratic system, which we all denounced liberally. ‘
Representative
HELEN Field
BONN,
in a Mental Health Center: A Commentary
& COMMUNITY
PSYCHIATRY
at
‘
‘
Still another demonstration of fuzzy thinking was the idea that using power is inherently evil. What we really meant was abusing power, not using power. Thus fuzzy thinking, combined with role-blurring, contributed to the chaos Ms. Doyle described. For years the health field, including mental health, has discounted administration and management as second-rate activities, whether at the front-line treatment unit level or at middle or top management levels of the treatment organization. Thus the health field has tended to ignore the body of knowledge available to guide the development of health service organizations. As one consequence, organizational experiments such as the one described by Ms. Doyle continue to be carried out, to the detriment of all concerned-especially to the patients or clients receiving the services compromised by organizational ineptitude. An essential feature of effective organization and
management of health service delivery is what we and others call organizational preventive maintenance, which is analogous to the preventive maintenance of equipment and machinery. Such built-in organizational preventive maintenance allows for systematic input of every staff member’s contributions of relevant information and skills, aimed at the early detection of trends and problems before crises occur. Problem-solving in a crisis-oriented situation is likely to be a less rational and a more emotional process that is ultimately dysfunctional for all concerned. We suggest that Ms. Doyle’s mental health center staff were beginning to achieve the kind of control of their program afforded by preventive maintenance approaches when the tide turned. We commend Ms. Doyle for writing about an all-toocommon experience. Perhaps readers will learn from this experience and from other material in the literature before embarking on similar, ill-fated ventures.tm
Defi n ing the Differences Between Crisis Intervention and Short-Term Therapy R. STUART, PH.D. Clinical Psychologist KEMSEY J. MACKEY, A.C.S.W. Coordinator, Outpatient Department St. Clare’s Hospital Mental Health Denville, New Jersey MARIAN
Center
Using the model of “person plus stress yields reaction,” the authors discuss the differences between crisis intervention and short-term treatment, including psychiatric emergencies. In emergency treatment the central focus is on the reaction, or symptoms, while in crisis intervention the emphasis is on the stress and its quick resolution. In short-term treatment the focus is on the person and exploration of behavior patterns and feelings. The authors believe that the number of crisis cases handled by a therapist must be limited because of their exhausting
nature.
UThe proliferation in the past decade
The authors’ address Health Center, St. Jersey 07834.
of community mental has made psychiatric
is Outpatient
Clare’s
Hospital,
Department,
Pocono
health centers services more
Community
Road,
Denville,
Mental
New
available to the general public. Many of the centers provide crisis intervention and short-term psychotherapy without a clear understanding of the differences between the two modalities. The differences need to be delineated in order to facilitate more effective treatment. The term crisis intervention suggests that treatment is provided at a time when a patient or family is experiencing a particular crisis. A crisis is usually thought of as an emergency of some sort or a situation of acute stress. It is a time when a great deal of change is being experienced or perceived by the patient, who feels incapable of coping without help. Short-term therapy has been described in the literature as brief or time-limited therapy, ranging from one session up to two years of treatment. One way to apply those concepts is through the use of a model that provides direction for clinical understanding of the patient and his presenting problem. The model assumes that person plus stress yields reaction. Person includes everything the patient presents about himself-demographic data, family background, previous coping mechanisms, developmental history, value systems, and beliefs. Stress is the situation that the person is experiencing. Reaction represents the re-
VOLUME
28
NUMBER
7 JULY
1977
527
