(Peter Bestley, May2000 - peter.bestley@lineone.net)

People with mental health problems do not need crisis services. They need services which enable them to live lives that avoid crises. Rather than starting with a specification for a 'crisis resolution service' there is, I would contend, value in examining why people with mental health problems experience 'crises'. Averting a crisis is better and (probably) much cheaper than resolving one.

The experience of crisis
A crisis arises when the experience of the individual, within their present context, is no longer bearable or is dangerous to them or others.

People in a crisis may have a variety of needs, including:

• (temporary) respite from external situation
• (temporary) respite from symptoms (eg destructive voices, suicidal intentions)
• help with managing their external situation or symptoms
• hope - belief that things could be better
• a place of safety - if we cannot provide the above and there is a breakdown of trust or excessive impulsiveness to be observed and medically managed (possibly against their will)

I would suggest that the following statements are true as generalisations:

• Crises rarely happen without a preceding period of increasing deterioration
• the individual is normally aware of this deterioration
  
• the individual normally wants to avoid this deterioration and the consequent crisis.
  

(The fact that these statements are not always true is one of the reasons why the model of care that I am proposing in this paper cannot be the whole picture. On the other hand, even if the individual is not aware of their deterioration, their carer(s) often will be and may be able to take appropriate action.)

Where these generalisations are true we have the possibility of avoiding a crisis. The fact that we often fail to do this is due to many factors. Some of these are dependent upon the person with the mental health need, but others are due to the configuration of mental health services. Issues such as professional 'etiquette' and protection of limited resources create hurdles to be overcome by an individual needing help. Often it is only be deteriorating to the point of crisis that urgent assistance can be obtained. Even then, as things stand at the moment, obtaining that assistance can still be a slow, tortuous process with many opportunities for error.

The existing model

Existing crisis services operate on a model of 'assess and treat' (and this is also the model of the proposed Crisis Resolution Teams). In practice, particularly out of hours, this often means 'assess and refer on to another agency'. In most cases people in a deteriorating mental state do not want to be assessed: they want to be supported and helped. The 'assess and treat' approach no doubt comes partly from a simple medical model of mental health needs, but it no doubt also arises from services defending their own boundaries and hence responsibilities. Such a 'pass the parcel' approach to care, particularly for people in crisis, is profoundly unhelpful and dangerous.

Fundamental to this approach is the notion of the mental health professional being the 'expert' whilst the person in mental distress is the object of examination. In a world of limited resources, an important part of this examination is to decide whether or not the level of distress is sufficiently high to merit the use of a limited resource. This approach, whereby support is only given to people 'genuinely in crisis' means that there is a very real sense in which it can be argued that mental health crises are fundamental to the mental health system. If there are no safety nets, we do have to scrape people up off the ground.

An alternative model

There are five pillars I would like to propose for an alternative model for crisis provision:

• crisis avoidance not resolution . This is to be achieved by a much greater emphasis on crisis planning and ensuring that there is a graduated provision of support, rather than the existing model in which I have argued crisis is endemic.
• based around needs of clients not service providers. Existing services have been developed by professionals to meet the needs of professionals (eg professional etiquette requiring people known to the service to have to go through GP - even worse, out-of-hours GP service - to see on call psychiatrist)
• partnership between client and service, not confrontation. At the end of the line of a crisis service there is the possibility of a person being forced to have treatment that they do not want. However, the greater confidence that the client has that the service is 'on his/her side' the greater willingness they will have to engage with it. Part of this confidence may be achieved by service users being engaged in the management and delivery of the service.
• empowerment of client to deal with crisis rather than an 'expert' external solution being imposed. Under the existing scheme the professional expert assesses need, prescribes action. What is being proposed is that the client engages as their need varies. Clients are encouraged to become expert in their own condition and how to manage it.
• recognition of the expertise of people with mental health problems in dealing with mental distress, and hence their employment in providing crisis provision (after appropriate selection and training).
  The possible components of this sort of crisis service would be:
  

a crisis plan

this should be detailed, addressing such issues as

• what are the signs of becoming more unwell?
• what are the triggers of becoming unwell?what has helped / not helped in the past?
• what medication can be taken as needed to provide temporary respite
  access points to crisis services - knowing what to expect and how to access it
• owned by client - thought through by them, updated with their experience of using the plan
• accepted by mental health services as appropriate, with agreement to accessing services in the ways specified
• specific to their needs and capabilities (eg some individuals may be quite competent to make temporary changes in their medication depending upon their need, whilst this might be quite unsuitable for others)
• available to crisis services, so that they know what they are committed to providing.
• a relationship of trust / partnership between client and crisis service. This trust might be built in a variety of ways, such as encouraging clients to phone/visit crisis services when they do not need them, so they can know what to expect if they should use them
• a continuum of care rather than separate services 'passing the parcel'
  a place to phone for support. This might include both a generic service like the Samaritans and a mental health specific service which would be able to offer advice as well as a listening ear. (Possibly extend the Emergency Duty Team)
• a place to visit (locality based)
• a place to stay for a short time (locality based)
• a team to visit client at home (a crisis resolution team? - not necessarily mental health professionals)
• a bed in hospital for observation and treatment
• a bed in a more secure unit
• the encouragement of user-led mutual support groups (such as Depression Alliance, Hearing Voices) which can provide people with the basic level of support that they may need. These might also be developed, with appropriate training and payment to their leaders, to provide telephone support between sessions.
  the encouragement of befriending schemes where users can give each other mutual support.
  

No amount of dressing up would make these suggested developments into the Crisis Resolution Teams which we are supposed to develop without being given the appropriate resources. However, they are relatively low cost and do not require recruiting large numbers of scarce mental health professionals.

Let us make our temporary inability to provide Crisis Resolution Teams into a spur to improve services around crisis, rather than an excuse to do nothing until the resources are available.

(For a recent analysis of the sorts of service advocated in this paper see Being there in a crisis from The Mental Health Foundation.)

Peter Bestley May 2002 peter.bestley@lineone.net