#CrisisTeamFail

I noticed a hashtag on Twitter last night that made me feel quite anxious but also intrigued – #CrisisTeamFail.  Whether or not you’ve signed up to Twitter, you can still go on it and see the content.  In short, various patients were tweeting their experiences of contacting mental health crisis teams and noting the replies that they received – it was revelatory in many respects, although I’m familiar with some of the responses people received because of what I’ve heard and seen as an operational police officer.

Before we get into this, I want to go out of my way to make one thing abundantly clear and please imagine me in a raised voice so there can be little or no doubt that I really mean this! —

  • We all know mental health teams are under-funded – this is acknowledged right up to the level of HM Government ministers.  We know that NHS England chooses to apply a differential funding arrangement to mental and physical healthcare, ensuring a recent 1.5% and 1.8% rise in funding allocations last year causing Department of Health Minister Norman LAMB MP to make his views very clear and he has continued to do so.
  • We know that when demand exceeds supply of staff – this means they have to make decisions about what to prioritise.  Like other public services with finite resources, this means that from time to time you will not deal with things that you would ideally like to deal with.  Or, you will not deal with them as quickly or as well as you would like.  The police do this too – as a duty inspector, I personally took certain decisions to that effect.

So, honestly – we do get it!  The system is underfunded and ineffective and this is not the fault of frontline Crisis Team staff.  We know this because we’ve seen the Crisis Care Concordat looking across the board from commissioning and commissioners to the detail of frontline provision across providers, to see what can be done better and a lot of that will be about joining up over-functionalised silos in which various kinds of healthcare provision sit.  So really – we understand that ‘the system’ accounts for a lot.

Until it’s sorted out, we understand that decisions may be taken about what staff will or will not do and that this means some demand may end deflected to the 999 services, whether deliberately or not.  As long as we’re not asked to do things that are illegal or asked to assume responsibility for decisions we cannot possible make, there’s a certain degree to which I don’t mind, however much I’d prefer it properly sorted by correctly constituted mental health teams.

But this hashtag went way beyond all of that for me.

RAPE INVESTIGATION

In 1983, a fly-on-the-wall documentary was made in the Thames Valley Police area.  It included an incident where a woman attended Reading police station to report a rape and the documentary makers were allowed to film the interview of that victim by a Detective Inspector and a Detective Sergeant.  So these were supervisory CID officers.  We then watched the most awful berating and disregard of that victim and it quite rightly generated public uproar, leading to disciplinary proceedings against both and to a total overhaul nationally of initial responses to rape.  I’m afraid to say that the unfolding of this hashtag made me think of that.

Even now in relation to the investigation of rape as well as other offences, there are indications or perceptions in just some cases that victims question whether or not the police believed them. Of course, the operating presumption should be that people who walk into police stations tell the truth, unless and until something indicates otherwise.  Prosecutions for wasting police time or perverting the course of justice for false reports of any kind of crime are comparatively very rare indeed, perhaps the most recently notorious of which was the prosecution being faced by Eleanor De FREITAS which led this young woman with bipolar disorder to take her own life.  Validation for victims is achieved by the police taking reports serious and treating them as true allegations for the purposes of conducting a thorough investigation.  In Ms De FREITAS’s, case her father stated that he understood that inconsistencies in her allegation rendered a prosecution very difficult and why the police did not seek to bring charges against her alleged attacker.  That man then brought a private prosecution against her for allegedly making a false allegation against him and the CPS decided to continue the case, despite objections from her solicitor and family.  Very, very difficult issues.  Guidance to the Metropolitan Police would have made it clear however: upon first receipt of her allegation of rape, she is to be believed, validated and the investigators go wherever the evidence takes them.

This is what concerned me about the stated responses, which we all must acknowledge were made known entirely without context on a social media platform.  I’m sure mental health professionals involved in those conversations would have their views about whether comments attributed to them were accurate, or whether context alters anything.  But regardless of all that, it seemed clear to me that those patients tweeting their experience didn’t feel validated.  They often felt patronised or dismissed.  One example included a female service user who was asked whether she had considered going for a walk – whilst on her own, late at night and whilst feeling vulnerable.  Oddly enough, she didn’t wish to consider this.

DISTRACTION TECHNIQUES

The suggestions about patients having a cup of tea, a hot bath or a long walk were frequently mentioned, by many.  A doctor – who it must be said, was one of only a couple of professionals brave enough to become involved – pointed out that such things can be valid distraction techniques for people in crisis.  It must be fair to observe, few people found this acceptable: many were beyond that stage themselves before ringing the CrisisTeam in the first place.  Others had specific objections to the advice – like the woman who did not wish to go out late at night on her own for a walk.  Or the person in crisis who didn’t want to have a bath and see a body they loathed as part of their principal mental health condition.

A few mental health professionals have then since made the point: there are far two few professionals in a crisis team to necessarily provide an effective response, that they are trying their best and that in some situations, all they can do is encourage forms of self-care or distraction that may get someone through the night or to the next day.  But that moves us on to various tweets that made reference to the police.  It was someone tweeting about being ‘threatened’ with the police that first drew my attention towards the #CrisisTeamFail hashtag.  Now I’ve been the police officer sent to a home on many an occasion and I’ve taken advice calls from PCs and sergeants hundreds of times about such incidents.  There is often a very stark difference between the 999 call made by the CrisisTeam and the response to officers from the patient.  Of course, this could be for any number of reasons: might I be bold enough to suggest that occasionally, the risk to a patient is occasionally exaggerated to ensure the police do respond and become responsible?  Might I also suggest that sometimes, patients are so surprised, intimidated or unwell that when cops with stab vests and tasers suddenly appear at the door, they quite naturally attempt to downplay their crisis for fear that they will be detained in custody to keep them safe?

Regardless of the explanation, I know this – the police can confirm whether someone is Alive, Breathing or Conscious and whether they are obviously Ill, Injured or Intoxicated.  They can even inform the CrisisTeam of these observations – ABC/III. Whether this means that a person is ‘safe and well’ is a totally different assessment and not one for the police to make, ever.  It does not ‘tick off’ a discharged duty of care that the Crisis Team called the police, except in the sense of mitigating an immediate threat to life.  If the officers pitch up and find someone in similar circumstances to which the principles of the Seal, Sessay or Hicks cases apply, then the officers have no legal powers to act whatsoever unless there is also a criminal offence being committed or attempted.  So the Crisis Team will still have to decide: “what are we now going to advise, if anything?”  They are effectively back to where they were before they called the police because mental health care in this country is the responsibility of mental health trusts and general practitioners, not the police.

This hashtag – for me at least – showed how important it is to have good communication skills, to have a response that doesn’t sound like people are being dismissed or even disbelieved and to validate people’s experiences even if you are on the way to providing a response that may not be what they had hoped would happen.  Some people reporting crimes as victims aren’t victims at all – no matter what their belief to the contrary; and some are actually telling lies.  Only a professional investigation will properly determine into which category someone falls and you’ll never get that in an initial phone call.  I can’t see how mental health care is any less complicated!

Maybe some patients aren’t in full-blown crisis when they think they are – some victims aren’t victims when they think they are – it sometimes takes more than a conversation on the phone, not only to make this clear but also to explain it and then further support someone.  This will be no different in those seeking crisis care responses – your perception is your reality and if we’re talking about a group of patients experiencing suicidal ideation or delusional ideas, however short that falls from whatever the definition of ‘crisis’ is, it is effectively denying the significance of that experience by providing a response that doesn’t work for the person, and is therefore no response at all.

But I repeat my original point: if this is about the capacity of CrisisTeams, then commissioners and managers need to look at that.  But this is also about how frontline staff communicate, which – of course – is an issue in the police too, especially when pressure is on professionals to deal with volumes.  Managing sensitive, high-complexity demand sometimes takes time that appears not to be there.  If this is about how vulnerable patients come to better understand how to support themselves in crisis, then who could object to that.  But if it is also about how we communicate with people.  The police are busy and being ‘rationalised’ too, but I was glad to read remarks in this hashtag that patients found that the police listened, cared and tried to help whenever they were involved.

So if all else fails we seem to ring the police – and I wonder if CrisisTeams do that more now many police forces have access to street triage?!  Various pieces of anecodatal evidence made known to me suggests that we are – but that’s another post altogether!


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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16 thoughts on “#CrisisTeamFail

  1. Can’t believe I’m the first to reply..! Hot topic!
    I could write an essay, but I won’t. Glad you’ve covered what I call the “circle of doom” crisis team-police-crisis team loop (with the occasional A&E doctor or out of hours GP thrown in for variety).
    One thing I have noticed is that the response I get from the crisis team is significantly better now than in the past. Part of this is to do with changes in the system (some people previously excluded for PD label pre 2007, new staff coming in without these attitudes), part to to with what’s in my notes, and part something else maybe? It’s seriously dodgy that one gets an invalidating response based on what diagnosis you have/how your problems have been judged but that’s one for psychiatry I think! (Though an explanation I believe for why some people find th police more humane than the crisis team…) Anyway, I know that despite cuts to the service, I’ve had a better response. The difference in response lies not in the amount of time/hospital/resources spent on me (in fact that’s decreased, esp. incuding police time), but how the crisis team have spoken to me. Even if someone politely explains they are very busy, could I phone back a bit later, and sounds concerned, it is so much better than simply minimising my distress and fobbing me off. I once wrote a joke job ad for the crisis team, including things like “zero empathy” and “poor listening skills”… it’s all in the interpersonal skills!

  2. A good crisis response is dependant upon a good crisis contingency care plan which should list relapse indicators enabling the duty response officer to give effective advise. I don’t work for the crisis team in my area but i do provide a crisis response to all service users known to our Complex Care & Treatment Team between the hours of 9-5 Mon – Fri.

    Every known service user subject to CPA should have a care co-ordinator who ideally would be the person responsible for providing an effective response to a person on there own case load. The duty officer only takes the call if the care co-ordinator is unavailable due to annual leave/sickness or is otherwise engaged in co-ordinating the care of another service user on their caseload. We have case loads of around 35 people each per care co-ordinator and are expected to see many of them once per week for an hour. There is also an expectation to make 5 face to face contacts per day however in reality this target is quite often unacheivable. After every contact telephone/face to face an electronic record is uploaded, after every CPA review the outcomes/plan is recorded, in addition to these records there are expectations upon us to upload care plans, crisis/contingency plans, discharge care plans (for those leaving hospital) health & social needs documents which consist of over 24 questions.

    I will continue….The care co-ordinator writes the social circumstances reports and presents this at mental health tribunals, completes carers assessments, completes adults/child safeguarding referrals/reports. Anything else the care co-ordinator is responsible for? Well actually yes, we are the purchasers of community care packages SDS (Self Directed Support) so we complete a RAQ (resource allocation questionairre) then a support plan, we then interview suitable provider/brokers and make a decision which of these can best meet the needs of the service user. Once we have a provider/broker we then use a new system called Liquid Logic (Replaced ISSIS recently) the social services IT system to upload all this data and apply for the funding. On many an occassion we are then told by our commissioners (CCG’s/health care or local authority/social care) that the package of care we are proposing does not appear cost effective or that there is another preferred provider. I have not mentioned the many hours of mandatory and essential training that we must complete throughout the year, the letters we write, the meetings with other agencies/partners we attend MAPPA/MARAC etc etc…I have digressed.

    I realise that as this tweet is entitled #CrisisTeamFail however we should remember that the crisis teams are not always front line practitioners and at times have no prior knowledge of the person on the end of the telephone that calls them after 5pm or over the weekends. The crisis team staff and their responses (Distraction techniques) should always be guided by the information held on the system within the crisis contingency plan, or community care plan, alas, i suspect many practitioners find that the plan is either not there or out of date because guess who’s responsibility it is to ensure it is? Yes the care co-ordinators. I don’t think anyone reading this will be surprised to hear that many highly qualified mental health professionals are becomming disillussioned by care co-ordination due to the excessive responsibility these amazing individuals absorb. On a daily basis, i hear the term fire fighting, being reactive, very rarely proactive. Is it any wonder sickness rates for care co-ordinators are rising, and as a consequence the highly skilled members of staff are leaving due to the realisation that they cannot provide safe and effective interventions thus reducing the quality of staff interested in these positions. I am but one person and yes I am a care co-ordinator that loves his job, I also believe and have been told many times that i have excellent interpersonal skills, i am a psychiatric social worker employed by my local authority, will I still be working in a mental health team in a years time? I sincerely hope so, as social work and everything that fulfills the job description runs through me like the writing through a stick of rock. I am a strong resilient person, I very rarely feel stressed, i have a great understanding of my emotional intelligence, I could resign from my position tomorrow and work for one of the many agencys thats contacts me on a weekly basis, but for now I am hoping for change and staying optimistic. I cannot say the same for many of my colleagues and that is the real travesty. I hope I have provided a little insight into some of the current pressures within mental health services, many thanks, Mr D

    1. Can I ask aout your comments above – it always seems to me that services seem to lack good administrative staff who could do much of what falls into your job currently. Is that wrong?

  3. Like Myrtle, I could write an essay about my experiences with crisis teams over the past seven years (three teams in two boroughs). Suffice to say none of the experiences have been good. I have refused to work with the crisis team since 2012 except when it is necessary for them to sign off on an admission to the crisis house. The reasons for the refusal are much the same as others have given on Twitter. Crisis teams are a last resort. We contact them when our usual means of distraction and ways to keep ourselves safe have failed. Being told to have a bath when you are sobbing down the phone explaining you are so depressed you haven’t even been able to brush your teeth or get dressed in a week isn’t helpful. If you are in crisis, with a plan and the means to cause serious harm to yourself, then being told they will call back in half an hour isn’t good. When they do not call back until a couple of hours later, by which time it is too late, they have failed to provide a crisis service.
    I understand the teams are underfunded and understaffed but in the long run it doesn’t save any money. In the example I have given I ended up being taken to A&E in an ambulance, psych liaison still had to see me, I absconded as A&E was not a suitable environment for me when I was experiencing that level of distress so there was police involvement (section 136), I was then admitted to a medical ward and ‘specialled’ (one to one care for several days can’t be cheap) before finally being discharged and told to WORK WITH THE CRISIS TEAM!
    Any savings from lack of funding for crisis teams is short sighted. I am a mere mental patient and I can see that. For all my moaning about crisis care I will say there has been one huge improvement in my area. We now have three crisis houses (one specifically for women) and these have helped to keep people, myself included, out of hospital. I can only hope that people who work in crisis teams and those involved in allocating funding read these tweets. Perhaps then they will understand that it is a problem with the system rather than individual complaints.

  4. I work in a crisis team. I know that the team I work on works extremely hard – all of us with no exception – there are no ‘breaks’ and overtime is normal everyday. Of course we are not the only service to be stretched like this and we can’t let these things effect quality of service.
    When responding to a crisis we have to prioritise – GP referrals are being pushed and expected to respond within 4 hours which sometimes means more serious sounding referrals have to wait. -reading a referral – often if you are out in the community already you do not have access to previous notes so you are often walking in quite blind to a persons history and risk. The crisis is then based on exactly what you see and hear in the time you are with the patient. Assessment is done in twos by qualified clinicians to hopefully get at least two lines of thought in agreement about treatment. It is often easier to see when someone is acutely unwell and needs hospital admission. The harder and more risky option is to decide to home treat or not home treat. This totally relies on the information we gather and that’s where the risk is huge. Besides this the issue of communication with patients is a problem that I recognise in terms of letting patients know when we are running late etc but many community staff are yet to have a work phone due to money ( another issue for lone workers) and if you do its often you are running from one assessment to another – though again I totally understand that the phone call takes 2 mins and we should try harder.
    The mention of lacking in empathy does concern me more than anything, I have not witnessed this in my team though I’ve heard the accusation from people we see on occasions – some people will always see us as being unhelpful I guess and I know we try to address every complaint – if someone is not in a crisis and we explain this people can take this as we do not understand or we are being unhelpful – it’s important we make the patient feel validated and that can mean suggesting sleep hygiene signposting to MIND or elsewhere – they are genuine alternatives that can help.
    Sorry if my post is disjointed but I’m half awake and wanted to reply! I’d be interested to hear what others have to say. By the way only known out team to call the police if a patient is threatening or violent to themselves or others

  5. I think there may be issues around being clear to patients about what exactly is on offer. Frustration then occurs when the patient’s expectation is one thing and what is actually on offer is something else. As an example in our area there is an out of hours helpline. Realistically all they can ever offer is a listening ear if they aren’t too busy and a suggestion to go to the Urgent Treatment Centre or call an ambulance. If none of these work for you then that is it – there is no other out of hours service. Similarly we have a Home Treatment Team that are very good at providing treatment at home rather than having to going into hospital – but it isn’t an emergency service, and no one is going to come out in the middle of the night.
    But both of the above are proposed to patients as solutions for a crisis. Is there a difference in what people mean by a crisis? To the patient is the crisis point ‘ I have the means and I am on the point of using them to do harm to myself’? To which services might realistically say there isn’t actually anything we can do at that point……..And therefore for people who are already patients is the answer to stop matters getting to this point? Which then probably means more planned hospital admissions…..

    Would be very interested in what other people think.

  6. I recently found out that my local crisis team have been told they have to concentrate almost exclusively on s136 call outs to the detriment of everything else. This seems backwards to me, surely stepping in to prevent things reaching that level is the answer. I know they are chronically underfunded. I know they are chronically overworked but almost without exception I have felt more ill, more suicidal, more self destructive after I’ve spoken to them then before. I only call them rarely and when I do it is when I’m in crisis. To be called back three hours later and told to have a nice cup of tea doesn’t help. If I could distract myself I would, if I call them it’s because I’m beyond any of my coping mechanisms. It is incredibly frustrating.

    1. Interesting points ..but with all the slating of crisis teams from certain quaters is there truely a lack of understanding of the levels of stress and risk that crisis team staff face on a daily basis. Personally I have a significant amount of experience both on acute wards and crisis teams but don’t profess to know it all. To be honest I would say I have taken a great deal of verbal abuse and confrontation from other professionals who seem to take out their frustration at the lack of resources on front line crisis team staff. I have to say this blog appears to minimise or even belittle the use of distraction techniques quoting extreme examples rather than an emphasis on evidence based practice or even practice based evidence. The last crisis team I worked for had the highest rate of staff sickness in the nhs trust mainly due to stress. As a comment above section 136 patients were prioritised despite frequently being intoxicated with alcohol and not having any significant mental illness…with the police having their own resource issues quick to hand over responsibility to Crisis team staff. I honestly believe a mental health nurse somewhere will face serious injury or death from an incident related to someone intoxicated with alcohol.
      I no longer work in acute mental health care ( community mental health team now) . I miss working with people with acute mental illness …if it was just about nursing and supporting the patients it would be a fantastic job. Just a final point there is a difference in someone’s wants and their actual clinical needs

  7. Having watched this debate from the sidelines I wonder about psychiatry & what it really has to offer. It’s what we as a society have invested in & are told works & I have seen meds & talking treatments & ECT work for v ill peeps. But on the flip side I am acutely aware of the side effects of treatment & of the sometimes damaging affect of hospital admission under section – it is after all what I do sometimes. I always try not to & when I do, I attempt to do so with care & compassion. Btw I have seen it not work also 😦

    I have also witnessed great compassion & no little skill on the part of nursing colleagues & medics seeking to manage distress, psychosis, hopelessness & risk in the community (HTT). We/they are not all perfect & don’t always get it right, nor are they/we equipped or resourced to manage the expectation & demand placed on them, indeed no public service is. I also witness everyday the damaging effects of poverty ,violence, family breakdown & substance misuse.

    I am not seeking to make excuses for lack of empathy or basic good manners & understanding. Remember it’s us to on the receiving end (1 in 4), or my mum, dad, brother, child, friend ……

    The debate should be had & I would like to think that we would all arrive at the same conclusions. So from those in charge (& in theory that’s us) the message should be to politicians, at both local & national level & the leaders of public bodies, NHS trusts & commissioners & LSSA – etc give us what we want & need, a fair share of the £s, or at least be honest enough to spell out the limitations of what we currently have.

    Take care of u & yours

    1. As a relative of people with serious mental illness (schizophrenia and severe depression) please don’t knock psychiatry. The reality for some people is that without medication they would be dead, or at best unable to function in any meaningful way. Like all modern medicine psychiatry is still relatively new, but we don’t say cancer treatments are useless because they don’t cure everyone and have horrible side effects. Yet there is a worrying tendency to say that about treatments for mental illness…….

      1. Hi Judy
        Me only giving it a little knock/tap. I acknowledge that it does work for some, even many maybe.

  8. In the wake of the whole #Samaritansradar debacle, it’s curious to read this from the other side of the gate, so to speak. Over the years, I’ve found very mixed responses from those supposedly trained to respond to crisis. Most severe recent crisis was the result of an undiagnosed PHYSICAL illness affecting my mental health, but the young woman I saw as a an urgent case was condescending, disrespectful and unhelpful to the extent I was reluctant to risk ever seeing her again. There are some who go into psychological care careers who lack the empathy and imagination to be of any real use.

  9. Is the issue actually that too many people aren’t receiving the care they need to be able to live safely in the community. If people are living on their own then services are having to provide not only specialist care but also the care that a family would provide. Yet many people are expected to cope with living alone with serious mental illnesses. In fact the recovery star model encourages the user to think that they need to live independently as fast as possible…………

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