Thursday, 20 August 2020

WHAT IT’S REALLY LIKE TO BE UNDER THE CARE OF THE CRISIS TEAM




“Never give up on someone with a mental illness. When ‘I’ is replaced with ‘we.’ Illness becomes wellness”

Shannon L Alder


The Crisis Team are definitely an element of mental health which is misunderstood, and the Teams are often the ones who receive the most negative feedback. In this post, and as someone who is currently under the care of the Crisis Team, I hope to promote a better understanding of them and instil hope in others to utilise their local Team for help and support in a mental health crisis.


The first instance

My first memory of an interaction with the Crisis Team is from 2009 when I had attempted suicide through taking an overdose. Somehow my Mum knew I had done it and she tried to convince me to go to hospital for the potentially life-saving antidote treatment. I refused and she asked what she was supposed to do, and I remember telling her “ring the Crisis Team because it sounds like you’re in a crisis!” To be honest, I don’t remember actually speaking to the Crisis Team, but they came to the house and arranged for me to have a Mental Health Act assessment with two Psychiatrists and an AMHP (Approved Mental Health Practitioner). I was detained under Section 2 of the 1983 Act and the Crisis Team opened the door to allow six Police to march in, restrain me, handcuff me, and carry me out to their van.




The impact of the first memory

When I recently trained the British Transport Police (you can read about it here) I said something which I think runs true for the Crisis Team too; ‘the people you support could be uncooperative but it isn’t always just to be difficult.’ I explained that rightly or wrongly, each Police Officer – or each member of Crisis Team staff – represent the organization they work for and so an experience with just one member of staff can shape a person’s view of the entire organization and all it’s employees. It meant that that first memory of the Crisis Team shaped my attitude toward them for a long time afterward. And it didn’t matter if it was a completely different member of staff coming to see me, I associated the Team as organizing for me to be taken to hospital against my will. Sometimes, this was a good thing because it meant that if I was being uncooperative and was threatened that the Team would be called in, I would most likely shut up and do as I was told! But then, it was also a bad thing because it meant that I was incredibly reluctant to utilize their service and call them for help and support when I was in a mental health crisis.


The BPD stigma

When I was diagnosed with Borderline Personality Disorder (BPD) in late 2009, I was warned that it was like a ‘death sentence’ because no services understood the Disorder and therefore they couldn’t provide efficient or helpful support to someone with it. I definitely saw this attitude in the Crisis Team when my diagnosis quickly turned them from getting me sectioned and hospitalized to accusing me of being an attention-seeker! I remember one time when the Police found me wandering down a dual carriageway and they called the Crisis Team and came off the phone saying “well they said you do this for attention so get out the car and make your own way home.” At the time, I was so angry and upset that I didn’t realize why they would adopt that attitude toward me and saw it as plain insulting and dismissive. Over time though, I learnt that this attitude was based on a very deep misunderstanding of BPD and the symptoms someone can experience.


Could they have changed what happened?

I do wonder though, if the Crisis Team had changed their thought process and attitude towards Personality Disorders much quicker then would I have still ended up on life support and then sectioned for two and a half years? If my diagnosis was understood and the impact it had on my life appreciated, then would I have had to be hospitalized over 100 miles away from home because there were no Personality Disorder services or hospitals in my locality? As it was though, their outlook changed during the two and a half years I was in that specialist psychiatric hospital over 100 miles away! 


The improvements

Coming back, it was still so difficult to trust them and to feel confident that they’d provide efficient care whenever I was referred back to them or where someone recommended, I call them. I ended up very pleasantly surprised when I would have contact with them and they would say all the best things and do everything I needed in a crisis! It meant that I wasn’t completely against the idea of asking them for help and support whenever my mental health deteriorated. And whilst there were still some staff on the Team who weren’t so helpful; those that were far outweighed them! It was almost like using a scale to consider just how bad the bad ones were and compare them to the level of how great the rest are!

I think a huge contribution to the improvement in the Crisis Team came from their Management team. I also believe that the Team improved in their response to someone with BPD because they’ve put more effort into education on the Disorder to gain a better understanding as to what is helpful for someone with BPD who is in a mental health crisis. I think they learnt that BPD can be a very complicated and overwhelming Disorder which can influence so many behaviours in a person which they might not usually exhibit unless they’re in a crisis. I mean, I consider myself a completely different person in a mental health crisis because I’ll say and do things that are so far from my norm and the morals and ethics I hold that it’s sort of unbelievable it’s all coming from me!


How the assessment came about

So, when, I found myself walking to the harbour with intense suicidal thoughts in my head and my hand bleeding, I actually opted to call the Crisis Team above all the other people I could have contacted. I explained that it felt as though only 5% of my head was controlled by me and the rest had been held hostage by the hallucinations and I was using the little bit I was in charge of to ring the Team in a desperate attempt to find someone who could encourage that percentage to grow. I knew that when I was in charge of myself, I didn’t want to die or self-harm; yet I felt there was nothing I could actually do to take control over the hallucinations for myself and was certain that I needed help to do it. As soon as I told the Crisis Team what I was going to do, they called the Police who found me just metres from the harbour.

After a few negative comments from the Police Officers who took me to A&E to have my self-harm wound checked, I resolved to avoid all professionals and ignored the Crisis Team’s numerous calls after the Police told them I was home. After a bit of sleep I finally listened to the Team’s voicemails and when one of the staff said that she believed I needed to be assessed by them, I finally returned the call and agreed to an assessment with two of the staff later that day.


What happens at a Crisis Team assessment?

I think that one of the two staff who came to my home said we’d met before, but I didn’t know the other one. Having had previous experience with the Crisis Team before, I knew that one huge challenge in being under their care is that it’s quite rare to have the same two staff come to your home each time they visit. This obviously makes it difficult to build a therapeutic relationship with any one staff member, but it also means that having the opportunity to meet lots of different professionals will improve the chance of you coming across someone you find helpful and supportive. I think that this challenge was a little more intimidating at an assessment than it has been in their subsequent visits because I was so much more vulnerable at the assessment stage. Fortunately, I’m obviously a very open and honest person and I knew that if I didn’t tell them everything then how would I get the right level of help or support?

Some of the questions I was asked during the assessment – and my answers – were:

1.    “What do you think has caused you to self-harm?”

I feel that I’ve been asked that question by every single professional involved in my care – from the GP, to the Police, to Nurses… I’m definitely someone who likes to process things in a desperate bid to develop an understanding as to why something has happened. I think that mostly stems from being a Blogger because it has meant I’ve been able to reflect on a lot of things and realize that I can only learn from something or move past it if I understand it. This all means that when professionals ask me why I’ve self-harmed or attempted suicide I can pretty much always provide them with an answer. And this questions at the assessment was no different – I believe that my relapse – the reappearance of the hallucinations, the self-harm, the suicidal thoughts – have completely stemmed from my pharmacy’s mistake (which you can read more about here) in failing to order my antipsychotic medication for over a month!

You know, sometimes I’ve been able to look back and say “oh maybe it’s because I didn’t deal with this when this happened” but there’s literally nothing that would sort of fit into the time frame of my mental health deteriorating. Just the Pharmacy’s massive mistake!

2.    “How do you feel when you’ve self-harmed?”

I guess that in asking this, the Crisis Team are really solidifying that the thought everyone self-harms for the same reasons or that they have the same goal, is a complete myth. I think it’s so important to find the ability and the power to recognize your thoughts and feelings in general, but more so when it’s around self-harm or a suicide attempt. I think that with everyone being so different, some people may self-harm and instantly consider it a mistake or regret. I definitely struggle with the idea of this… I never want to have regrets in life and I think that I fight this where self-harm is involved because I know that in that moment, I’ve honestly felt that self-harming was literally the only way to cope or the only way to improve things.

My most recent self-harm has really challenged that anti-regret attitude I have though, because the consequences of it have been so serious and life changing. I mean, how can you not at least question the necessity of the self-harm? How can you not think ‘did I really have to make that cut that’s now left me with permanent nerve damage?!’ Was it really essential? The only way to get through how I was feeling at the time? But it’s also about choice and I 100% believe that I’ve never ‘chosen’ to self-harm. I’ve done it because I’ve felt backed into a corner and if – for one second – I had felt there was an option, I would have taken it!

As it is, when I self-harm I actually most often feel instant, immediate, relief. Relief which feels so short-term that it’s almost as though I’ve blinked, and it’s gone! The overwhelming nature of the relief is so pure and fulfilling though, that I would usually say it was worth the longer term – often more painful – consequences to the self-harm. Though, maybe that says more about just how upset and distressed I was feeling to have felt that relief the length of a blink was worth the rest of the self-harm aftermath…

3.    “Do you have any friends or family you can get support from?”

I think that this question is usually asked to see if the professional/Team can find someone else to take some kind of responsibility for you and your safety rather than themselves. I get it a lot with the Police after they’ve sectioned someone, and they’re sat for hours in hospital and they’ll be sitting there going “why can’t your Mum come and sit with you?!” It’s a difficult situation because a almost reflex response is the feeling that someone’s trying to shirk their duty – Police constantly barrage mental health services users with the ‘duty-of-care’ line and yet they never hesitate to desperately seek for someone else to take over!

I guess there’s also the attitude of ‘well, what’re you here for?’ and ‘isn’t that your job?’ where mental health professionals are asking whether you can seek support from others. But I don’t think it’s necessarily always meant as a way to avoid responsibility, especially in this instance of an assessment with the Crisis Team. I think they were actually trying to be helpful and encourage me to consider that my support network might be more widely spread and vast than I may believe. But actually, this question just reminds me of how small (but still incredibly special) my circle of friends and family are; because two of my best friends moved to Scotland in the last year, lockdown has stopped me from seeing another, and I only really have my Mum and my Aunt as family members… Thing is, I’d rather have a few really good people than a lot of people who’re just average!

Accepting my support network is quite small, has meant acknowledging that this means professionals can play a huge role in helping and supporting my mental health. Sometimes this is hard because you can’t exactly choose them in the way that you can control your relationships with friends and family! You’re either assigned to someone or they just happen to be on duty when you come to their attention… you’re sort of thrown together over a very important aspect of life.

4.    “Have you been taking your medication?”

I completely understand this question because on a few occasions I’ve stopped taking my psychiatric medication – one occasion it was because I had the infamous belief that I was better and didn’t need the meds anymore (but really it was because they were working!) and the other was when I developed the irrational but incredibly real fear that I was being poisoned through the tablets. On both instances, my mental health relapsed so significantly that I was sectioned under the 1983 Mental Health Act and admitted to a psychiatric hospital.

I guess that this has made it almost standard that if my mental health deteriorates professionals would assume it was because I’d stopped my medication. This question also helps the Team to determine a cause of the deterioration and, as I said before, figuring this out is essential to discovering what might help me through the crisis. If things had worsened because I hadn’t been taking my medication, then the Crisis Team’s plan to support me would be different than if there’d been a new trauma or something upsetting.

5.    “What do you think you’d do if we didn’t put you under our care?”

I absolutely can’t stand this question because it worries me that it’d sound like blackmail to answer it honestly and say that I’d probably end up attempting suicide or continuing to self-harm. I worry it’d sound as though I was saying ‘put me on caseload or I’ll kill myself’ and with my BPD diagnosis being surrounded by the belief that someone with the Disorder is manipulative, I’m even more paranoid that it’d be interpreted that way.

I try to remember though; they’re asking the question for a reason and it’s most likely to gage my safety level and whether they could rely on me to remain safe if I wasn’t under their care. It also enables the Team to establish whether being under their care would even be sufficient enough to support me to stay safe – it’ll help them to establish whether admission to a psychiatric hospital is necessary instead.

I told the Team that I felt as though I had tried my absolute hardest to keep myself safe but that since the deterioration seemed to have stemmed from not having my medication as opposed to an actual relapse; I found it too challenging to manage my safety alone. Where it is a relapse with the BPD, I feel that I can usually cope with it by using my Dialectical Behaviour Therapy (DBT) skills to stay safe and well. With this being the hallucinations and Psychosis, I felt at a loss in attempting to find a skill that would make even a tiny improvement. I explained to the Team that I believed without help or support, things would just get worse and I’d be even more unsafe.

6.    “How do you think we could help or make a difference?”

I don’t know why but it seems as though at some point in recent months, medical professionals have been advised that they should ask the patient either what they think is wrong, or what they’d like the Doctor or Nurse – or Crisis Team – to do. I think that it’s mostly to encourage the person to be as involved in their own care as possible, but sometimes it can come across as though you’re doing that person’s job.

I’m always uncomfortable when I’m asked these questions because I worry that it’ll look as though I think I know better than the professional. However, I’m a firm believer of the idea that we know our own mind and body better than anyone else, and so we tend to know what will help us – what we need. Some people just need more confidence to tell someone.

I think this question is also important because it will solidify any concerns over the person’s expectations of what the Crisis Team can offer as a service. Having been under the Team’s care before, I already knew the help and support they could provide and so I had a good understanding as to what they could do for me. I explained that I thought it’d be helpful to have daily visits with the Team for a little while so that I had someone to voice everything that was being said by the hallucinations. I thought that in being able to tell someone those things, there’d be an opportunity for that person to reassure me and rationalize the psychotic beliefs and experiences I was having. 


The impact of the decision-making process

The assessment team checked whether it’d be ok for them to have a little discussion between themselves outside of my home and then come back with a plan and of course I agreed but those minutes that they were outside – and which I knew they were talking about me – were so difficult! I genuinely kept wanting to pop my head out every thirty seconds to see if they’d reached a conclusion! I think assessments surrounding mental health can be extremely challenging for the service user or patient because more often than not, the assessment team won’t always give a response during the assessment and it leaves the person feeling uncertain and maybe even just curious as to what the conclusion will be.


Their decision

Firstly, after confiding in the assessment team that I was experiencing new hallucinations, they concluded that we could pinpoint the cause of the relapse to my Pharmacy’s error in failing to order my anti-psychotic medication. This meant that it would hopefully be a case of getting the medication back into my system for me to then be safe and stable again. With anti-psychotic medication usually starting to work fairly quickly compared to other psychiatric medication e.g. anti-depressants, the Crisis Team also advised at the assessment that I request my GP increase it as they believed if the old dose were going to work, it would have by then.

With this in mind, we could establish that being under the care of the Team would be short-term and that since I had been discharged from my Community Mental Health Team (which you can read about here) it was necessary to have the Crisis Team involved because otherwise I was without daily professional support (I obviously still have my Richmond Fellowship Support Worker). And with my first day in the office of my new voluntary job at St Oswald’s Hospice coming up, I suggested I go under the Crisis Team’s care only until then. I thought that having extra support might be crucial for me to be able to feel capable of going into the Hospice and that being discharged from the Team the day before going into work, would feel like a great achievement to put me in a good, positive mood.


The appointments

The Team began visiting me every day after the assessment and every single appointment helped in a new way! First, one of the staff suggested I make a ‘Hope Box’ and I immediately loved the idea. Once professionals hear that I have somewhere in my home where an excessive amount of paracetamol is stored, as well as sharps and various wound dressings, I think it’s almost their natural instinct to suggest creating a space for the opposite of those things. A space full of positive and healthy coping skills that will safely support me through a mental health crisis. Whilst this idea of a self soothe box helps a lot of people, I find it more helpful to have to purposely seek out each helpful object and product from around my home so that I have a focus and goal as opposed to purely opening a box and finding everything there in front of me. A Hope Box, however, struck me as something completely different (though the leaflet the Crisis Team gave me admits it can be referred to as a self-soothe box and many other names!). A huge emotion I struggle with when I’m really in a mental health crisis is hopelessness and so the thought of me having a box with literally everything that would remind me that there’s hope and that there are positive things in my life – reasons to live – felt comforting and definitely something I wanted to dedicate my time to. I think that just the act of creating and decorating the box has proven therapeutic so far (don’t worry, I’m vlogging the entire process!).

Probably the most memorable appointment has been when I had self-harmed just before the Team came to do the visit (they don’t give exact times just a ballpark e.g. any time between 5:30 and 8:30pm). I remember being so terrified to tell them what I’d done because I wasn’t sure how they’d react; what they’d do or what they’d say, so I held my hand (that’s where I’d cut) behind my back and thought I’d get away with it until they noticed the blood trailing after me! After some reassurance and encouragement, I showed them the cut and they decided a trip to A&E was called for! I was so relieved when they got permission to take me there and stay with me. Not just because it meant I wasn’t alone, but also because being under their care meant I wouldn’t have to see any other mental health professionals or have any assessments!

Unfortunately, I’d gotten a sensation and pain in my thumb from the cut, so the A&E Consultant had to refer me to the Plastic Surgery team at another hospital and I was allowed home until the appointment the following day, and the Crisis Team brought me home.

Another of the most meaningful appointments with the Team came after the Plastic Surgery team told me that even after surgery, I had permanent nerve damage, and one of the staff told me that she’d experienced nerve damage in her thumb too! I know that might sound a little silly to say that something like that was so important and meaningful to me, but being told that even after the surgery, the nerve damage I’d caused through the self-harm was permanent; I was obviously beyond upset. And I was desperate for some sort of empathy from another person, someone who could identify with me and have some understanding as to what I was going through and how I was feeling. So, to find that validation from someone, meant a lot to me. It helped too because ever since I first made the cut, I’ve struggled to describe the sensation and pain I experience in my thumb and whilst this member of staff didn’t have the exact same symptoms, she could appreciate the difficulty and challenge in describing it.


How it feels to have a friend under the care of the Crisis Team by Martin Baker

Aimee invited me to share how I feel when she is under the care of the crisis team. We’ve been friends for several years and over that time Aimee’s mental and physical health has varied a great deal. There have been times when she has been very poorly and times when she has – from my perception at least – been far more stable and well. Obviously, I’m happy when she’s well but our friendship does not depend on how she’s doing.

I also know enough to recognize that the healthier times do not happen by accident. As is true of other friends who live with mental illness, the work Aimee puts in is, frankly, staggering to someone like me who has no equivalent lived experience. I trust Aimee to do the very best she can to stay as well and as safe as possible. Most of the time, she is more than capable of doing that on her own. That includes taking her prescribed medication and employing techniques and strategies she has learned (she has blogged about these extensively). At other times, she benefits from specialised, professional input, including the Crisis Team.

Aimee knows I respect her instincts as to when to seek professional help. I’m not naïve enough to imagine professionals always get things right but in general, I feel Aimee is in safe hands when she is in hospital or under the Crisis Team care. It doesn’t distress me that she needs that level of support for a time. We have been through some rough times and I know there are occasions when she needs that level of care. I would be much more distressed if Aimee refused professional input or it was not available for some reason. Bottom line, Aimee is one of my very best friends. I love her dearly and want the very best support in place for her when she needs it.


Discharge from the Team

As I write this post, I’m still under the care of the Crisis Team but with the goal of discharge in the next few days (after being on caseload for almost two weeks). Originally, it was going to be a few days of daily visits and then discharge but I told the Team that I was worried it’d be too much to go from that level of support to suddenly having pretty much nothing and asked if we could gradually reduce the visits.

As the discussion of discharge looms, I find myself wondering whether I’m ready for it. I mean, I literally just had surgery for self-harm so how can I be? But now that I’m back on my medication, the hallucinations are dying down… they’re not there as often, but when they are, they’re just as overwhelming and controlling as ever. Still, it means things are improving and they’re on the ‘right track.’ And the thing with the Crisis Team is that usually the intention behind putting someone on caseload, is to stabilise them as quickly as possible and then discharge. They’re not meant to be a long-term service.

Another aspect of discharge has been my mindset and the thought process around what it means to my mental health recovery. Did being under the Team mean I’d relapsed? So, does being discharged mean I’m back in recovery? Does it mean I’ll be stable from now on? That I’ll never self-harm again? Or will I still struggle? I think that the best thing to do to cope with all of these thoughts and doubts is to recognize discharge from the Team as an achievement and something to be proud of and to celebrate. 


Advice for other Crisis Team service users

1.      Be honest

2.      Be open to their advice and recommendations

3.      Ask for what you need

4.      Know you might not see the same staff each visit

5.      Realise that being under their care shouldn’t mean you lose hope for a recovery