A report has been published this month which reveals that three times as many people die by suicide under Crisis Resolution and Home Treatment teams (CRHT) each year as in psychiatric hospital:-
"Suicide under crisis resolution home treatment" (Isabelle M Hunt, Louis Appleby, Nav Kapur)
This report is of particular concern and interest to me firstly because I have experienced CRHT and inpatient treatment myself, and secondly because I now run an independent Suicide Crisis Centre where we support increasing numbers of clients who are either currently under CRHT and need additional support, have just been discharged from CRHT at a time when they still feel at risk, or who have not found the methods of the crisis team helpful and have disengaged.
Indeed, I set up our Suicide Crisis Centre precisely because the crisis team, and the alternatives within the charity sector, didn't work for me, and I felt that a new and different form of support was needed.
CRHTs were set up as an alternative to psychiatric hospital. Their creation relieved the pressure on inpatient beds and allowed patients to remain in the family home and receive support there. Some people would much prefer to stay in a familiar, loving environment at a time when they are very unwell, and there is a percentage of people for whom home treatment works well.
However the report highlights the fact that people living alone or with limited social contact may be particularly at risk under the CRHT, especially after a significant life event (which may include divorce, death of a loved one, or loss of job).
My suicidal crisis in 2012 was triggered by an extremely traumatic experience ten days after a significant bereavement. I also lived alone. So I met the "at risk" criteria described in the report.
The report states that "a core principle of these services is successful engagement with the patient". I struggled to engage with the crisis team because of the number of people involved in my care. A different team member would come out to see me every day. There were at least eight people in the team supporting me.
They would come out to spend an hour a day with me. The quality of the relationship is paramount if you are only being seen for such a small proportion of the day. If you can build a connection and a trust with that team, then it can help to sustain you during the 23 hours that you remain at home unsupported. But with so many different nurses, I found that I simply couldn't build that connection and trust.
I found that the crisis team placed a strong emphasis on "distraction techniques" and many people are familiar with the phrase "What are you going to do to distract yourself?" when they phone the team expressing suicidal thoughts. While I understand the merits of this, it can be overused and sometimes used inappropriately. If you are highly distressed and are at imminent risk of suicide, you may not have the clarity of thought or the motivation or ability to distract yourself. It's important that CRHT teams recognise when a person has reached a point where distraction techniques are no longer working.
When I was under the crisis team there was a strong emphasis on practical advice. They suggested that I read gardening magazines at night because I was having difficulty sleeping. When I didn't do this, they recorded in my psychiatric notes that I had not followed this advice and cited this as evidence that I was not responding well to treatment. But it was simply that their suggestion didn't feel right for me. Gardening was an activity which I did in my previous life to create a beautiful place for the person with whom I lived at the time, before a traumatic experience shattered my peaceful existence. Reading such magazines simply reminded me of the life which I had lost.
Eventually I was admitted to psychiatric hospital. I was in a safe place, monitored by staff. Indeed, when my risk was particularly high I was on one to one observations and was watched 24 hours a day. That cannot be replicated at home under CRHT.
I also found the staff in psychiatric hospital particularly supportive. I have sometimes wondered whether the crisis teams' way of working creates particular stresses on them which can impact upon how they respond to patients. They spend much of their day out in the community and go out to visit patients either alone or with another team member. My impression was that staff in psychiatric hospital were better supported, having many colleagues and their management close at hand.
In psychiatric units, there are also opportunities for psychological interventions. Whilst under the crisis team, it became clear that I was experiencing post-traumatic symptoms including flashbacks in which I relived the traumatic event. I was also experiencing a post-traumatic condition known as dissociation (depersonalisation). I needed help and support with these symptoms but was told by the crisis team that I would need to speak to a psychologist about all this. I was also told that there would be a wait for at least eight months for this under secondary mental health services. If admitted to psychiatric hospital, you may be able to see a psychologist within days.
In terms of community care, we have demonstrated at our Suicide Crisis Centre that it is possible to provide a type of non-residential care which really can ensure that high-risk clients survive. We have been providing services for three years and have never had a suicide of a client under our care. We support clients either at our Crisis Centre or in their home.
However, I also strongly believe that we need to increase the number of psychiatric beds throughout the country which are available to patients who are in mental health crisis. This should be one of our actions, if we really want to reduce the number of people who die by suicide.
Information about the Suicide Crisis Centre in Gloucestershire can be found at http://www.suicidecrisis.co.uk
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