Editors note: this was originally published on Mad in america 28/10/2015 (update from Anne at the end)
Drayton Park women’s crisis house in North London offers an alternative to hospital admission for women experiencing mental health crises. It was Shirley McNicholas’ vision that brought it into existence and she has been leading the service since it opened. As it approaches its twentieth anniversary in December, she talks to Anne Cooke.
It was exciting going back to my old stamping ground. Years ago I’d worked in one of the local community mental health teams and had referred many women to the Drayton Park Crisis House. Walking up the steps of the house to meet Shirley brought back memories of standing there with desperate and suicidal clients, some of whom had told me that they would rather die than go back into hospital. As you can imagine, to say I had been glad that there was an alternative would have been an understatement.
The house is a large Victorian villa which looks much like its neighbours in a typical North London street. Shirley showed me round. The house was as I remembered it: furnished in a homely, ‘Ikea’ type style, with a lovely, airy living and dining space at the back overlooking the garden. Each resident has her own en-suite room, with a key, and there are cosy rooms for individual conversations and even massage. Residents’ children are also welcome. If I have a mental health crisis, take me there or somewhere like it. Unfortunately that’s unlikely to be possible – despite their overwhelming popularity there are still only a handful of crisis houses in the UK. I was keen to find out from Shirley how and why Drayton Park happened, and what has sustained it for twenty years. So on to my first question.
Anne: How and why did Drayton Park come into being?
Shirley: In 1994 I became co-ordinator of Camden and Islington NHS Trust’s project – instigated after extensive lobbying by local women – to create a crisis house as an alternative to hospital admission. The steering group shared a basic philosophy: a holistic, psychosocial approach to mental health, drawing on social constructionist and feminist ideas, on work highlighting the links between trauma and mental health, and on the service user/survivor movement. I was also personally influenced by systemic theory, having studied it at the Tavistock Institute. We wanted to create something new that would be robust enough to provide an alternative to hospital for women in acute crisis, but with a very different philosophy and therapeutic approach. Women were telling us that such a service was desperately needed. For my part, having trained as a psychiatric nurse and worked as a ward manager for many years, I was determined to create something very different to what I had experienced working in hospital.
Anne: Different in what way?
Shirley: The illness model – the idea that psychological problems arise primarily from problems in the brain and so need medical treatment – still dominates most of our thinking within services and is enshrined in law in the shape of the Mental Health Act. By contrast, social constructionists emphasise the power of ideas and language to shape our experience of the world (Gergen, 1985). This is nowhere more relevant than in the field of mental health, where diagnoses powerfully determine how people are treated, both within services and also in the wider world. It is not that diagnoses can’t be helpful, but they have immense power, leading us to view someone’s problems in a certain way and often to overlook other ways of understanding what might be going on. For example, they can distract our attention from ways in which the person’s problems might be related to their prior experience of the world. By contrast, a systemic way of thinking sees each person within the context not only of their family and their immediate social setting but also their social roles as, say, a woman or someone from a devalued group. It recognises that different people have different ‘stories’ about a particular situation or problem. None of these have a unique claim to truth, including those advocated by the ‘experts,’ but all impact powerfully on decisions about what might help.
Anne: So what does that mean in practice for how you do things at Drayton Park?
Shirley: One example might be the referral process. Professionals can refer in the usual way, but women, their families and friends can also self-refer. This obviously gives women more control, but it also makes an important statement about power and ownership. Over the years we’ve often had to resist pressure to limit or stop self-referrals, and go back to the old system where clinicians decide. People worry that the service might be abused or overwhelmed, that women who are not in acute crisis might get in. I think it’s interesting those questions are not raised when it’s clinicians who refer. We’ve fought hard to stick to the principle of ‘no decision about me, without me.’
Anne: What about mothers who are in crisis but have young children?
Shirley: Drayton Park is relatively unique in that children can stay here with their mothers. This can be a challenge, of course, but many mothers have the main or sole responsibility for their children, and even when they really need help they will often wait until they are sectioned rather than leave their children.
Anne: You are a women-only team. Tell me about that?
Shirley: Interestingly in 1994 this was not questioned and nor was the makeup of the team: the Trust and the local authority were open to trying a new way. We created a team based not on professional qualifications but on skills, experience and attitude. Compiling job descriptions was exciting: our ‘person specifications’ included an expectation that staff had an understanding of the relevant political debates, for example. Within boundaries, women are expected to draw on their own life experiences in their work. Staff come from a wide range of backgrounds including the voluntary sector and social care settings as well as psychology graduates.
Anne: So you were quite different to most services. How did people react?
Shirley: Really well, mostly. The service was hugely popular both with the women who used it and with local colleagues from all professions. We knew we were getting it right when audits showed that whilst the demographics and reasons for admission were similar to the inpatient wards, the feedback was much more positive. Women who stay here are choosing to do so, so the basis of the relationship was often different. Nevertheless, there is no doubt that the experience was very different too. Women told us that they appreciated the authenticity of the team, and that they particularly valued our willingness to hear and bear traumatic accounts, and to work jointly with women to contain suicidal feelings and self-harming behaviours.
Anne: You mention self-harm, which is often something services struggle to know how best to respond to. What is Drayton Park’s policy?
Shirley: This was something we gave a lot of thought to. We had learnt from specialist services, but we were also learning from each woman who came to stay. Women were often skilled in using alternatives to self-harming, and keen to participate groups and to try to understand why they harmed themselves. We agreed a policy that included staff keeping clean blades that women could use when nothing else was working. Although this seems dramatic and risky, it had a paradoxical effect, as the women knew it would: the knowledge that they could come for a blade meant that self-harming behaviour reduced. Women were also learning to trust others with their injuries. Our non-judgmental approach enabled many women to show their scars and wounds to someone else for the first time. We also had to work with women who harmed internally, inserting blades inside themselves. Again, although it felt counter-intuitive to those staff more used to working in settings which intervene by force if necessary to keep someone safe, we found a way of working that didn’t involve taking control away from the woman. We worked with each woman to be as safe as she could be, trusting her judgement but also being aware of our limits and being honest about this. It has been a very rare occasion where working with someone in this way has not been possible.
Anne: Tell me more about your risk management policy?
Shirley: Our policy has to be consistent with the Trust-wide one, but the basis is collaboration and psychological ‘containment’. It was a woman staying who first used those words, and I immediately recognised that this was a very useful way of describing how risk is held within the service. Rather than the ‘observations’ made in hospitals, we make contacts. The team follow a structured 24-hour timetable: at particular intervals each worker finds and connects with each woman she is allocated. We know that the woman is safe, and the woman knows that she is held in mind. The feedback about this has been very moving. People really appreciate not being left alone for hours in a bedroom, and knowing someone will come and find them. However withdrawn, irritable, or unwilling you are, your worker will come and find you. Each worker on every day shift offers a one-to-one session to each woman she is looking after, so everyone gets regular private time to talk.
Anne: What are the talking sessions used for?
Shirley: Often they are used to address practical issues or simply for support and reassurance. However, sometimes we listen and bear witness as women describe past and present traumas that are that are overwhelming and painful. We know that the majority of the women who use our service – and indeed other acute mental health services – have experienced trauma. It still amazes me how little attention is paid to this. In the two to three weeks that women generally stay with us, we offer counselling, grounding techniques, mindfulness, and help people develop coping strategies. We are also supported by a massage therapist whose input is highly valued by the women.
Anne: Do you think the physical surroundings are important?
Shirley: They are hugely important. We were fortunate enough to be offered a large Victorian house to house the service. This allows for a homely atmosphere with space for art and information. We’ve tried to create a space that is comfortable for a diverse range of women, and people certainly tell us that they find it a comforting and soothing environment. Our policy, which is on the notice board in every bedroom, is that staff will knock three times before using a key. This small practice has huge ramifications. It symbolises respect and privacy but also communicates recognition of the trauma that so many women have experienced, often in bedrooms. The simple act of giving people time to open the door powerfully communicates symbolically that ‘you are in control here’. The spirit of the Drayton Park model is reflected and perpetuated in the details.
Update: Since this post first came out on Mad In America, we’ve published two longer pieces. The first, ‘Women and Power: The Drayton Park Women’s Crisis House’ is a longer interview with Shirley and with Andie Rose, a woman who has stayed at the house, about the guiding ideas behind the service, how it was set up and operates, and what it is like to stay there. It is a chapter in the book ‘Inside Out, Outside In: Transforming Mental Health Practice (PCCS Books).The second is a piece of empirical research based on interviews with women who have experienced both the crisis house and also hospital: Coercion or collaboration: service-user experiences of risk management in hospital and a trauma-informed crisis house. Participants described hospital as being dominated by a medical-custodial approach, which they said was ineffective in managing long term safety and could compound distress. By contrast they described the crisis house as managing risk through relationships, enabling women to maintain some freedom, privacy and control. They felt this was a much more effective approach in the long term.
Gergen, K. (1985) The Social Constructionist Movement in Modern Psychology. American Psychologist, 40, 3, pp 266 – 275