bad-crisis-(0-00-00-00)

Crisis teams: the bad

19

Last week, we looked at a positive response from a mental health crisis team in New Zealand.  Over the next two weeks, we’ll look at the darker side of the services.

It’s Friday afternoon at 3pm, and I’m starting to think about the weekend.  I decide to take a break from my writing at the office, and phone up a mate to see what his plans are.

Five rings, maybe six, and he answers.  We exchange the usual greetings, and something seems slightly off, like maybe I’ve caught him in the middle of something.

“So what are you up to?” I ask.

There’s a long pause, and he exhales.  “Um…I’ve just finished writing up a note.  I’ve locked the car in the garage, and I’ve got a hosepipe ready.”  He speaks deliberately and factually, without any heightened emotion, as if he were talking about sneaking a Quarter Pounder meal when he’s supposed to be on a diet.  “I was just heading to the car,” he adds, more quietly.

“OK,” I answer, trying to keep my voice as calm as his seems.  “I’m going to get in the car right now and come over.  Do you think you can hold off doing anything till I get there?”

“Yes.”

I hang up, and try not to get overwhelmed by the fact that had my random thought about weekend plans popped into my brain ten minutes later I might not have got an answer on that phone.

I turn to my colleague Martin and explain what’s just happened, and race out the door.

I’m halfway there when my friend phones me up.  “The police are here,” he says.

“What?”

“I rang another friend after I spoke to you and he phoned 111 and they’ve sent the police here.  They’re taking me down to the police station.”

“OK,” I process this new information on the fly, thinking it bizarre that the police have been sent out to the home of a suicidal person where there’s clearly no indication of violence, or that the person is in possession of a weapon.  Where are the crisis team?

I tell my friend I’ll meet him at the police station.

Ten minutes later, I’m sitting in the waiting room at the police station, and I get another call from my friend.  “I’m at the hospital now.”

“What’s going on?”

“They were going to take me to the police station, but then they’ve stopped and had a talk to someone, and they’ve been told to bring me to the hospital,” he answers.

I head up to the hospital, already amazed at the blind confusion caused over how to deal with my friend’s emergency.  Although the two police officers were incredibly courteous and caring, he was still alarmed at their arrival, and while they’d told him he wasn’t under arrest, he says he was “strongly encouraged” to get into the car.  At no point was he told why he was being taken away.

In retrospect, I suspect the to-ing and fro-ing of hospital vs. police station was a game of pass the buck going on.  A pair of confused policemen were soon to be least of our worries.

I get through into the ward, where my friend is sitting up on a bed with a curtained-off screen around him.  He’s already had his clothes bagged and taken off him, and been changed into a backless surgical gown (as asked by Red Dwarf authors Rob Grant and Doug Naylor, why backless?  Why do doctors need to get to your arse in a hurry?)

We have a few minutes on our own, and my friend starts to tell me what’s been going on for him.  It’s a classic male story of pressure upon pressure that’s been building up for a year, and he hasn’t felt able to tell anyone about it.  Already, he feels embarrassed at the fuss he’s caused.

He tells me he’s been drinking non-stop since the start of the week, and not eating.  An incident had occurred at the start of the week where he finally hit the wall, and Friday’s aborted suicide attempt was the culmination of several days in the mental wilderness of despair.

“I really need help,” he says, in the same matter-of-fact tone he’s had throughout the whole incident.  “I just need a bit of time to recover, but I can’t be at home.”

This is not a man who would ever ask for help.  To the outside world, he is a paragon of strength and independence.  To make an admission like this is a watershed moment, and an incredibly vulnerable one.

From my cursory knowledge of the mental health system, I’m guessing that he’s not going to find it easy to get checked into a mental health ward, unless he is very clear about the fact that at present he is a danger to himself and needs to be supervised.  I encourage him to be utterly truthful about what has happened this week and how he’s been feeling.

In the meantime, various staff shuffle in and out with clipboards asking questions.  No-one identifies themselves or tells us what is happening.

Then come the big guns.  I assume they’re crisis team staff, although they do not identify themselves as such.  A man, and a woman.  She has the clipboard, he has the look of a social worker who’s been brought in to tell off a bunch of schoolboys for scrumping.

For the next ten minutes, my friend patiently explains how difficult things have been for him.  I remember holding his hand at various points because this was tough stuff to talk about.  As soon as alcohol was mentioned, the shutters went up.

The man changed into the role of a head dean crossed with a ‘Just Say No’ campaign volunteer, and started saying things like, “Well until you sort this drinking out we can’t help you.  Because it’s like the chicken and the egg.  Are you drinking because you’re depressed or are you depressed because you’re drinking?  We don’t know.”

The life events and circumstances that had been explained clearly showed to me that the drinking was a coping mechanism and not the root cause of my friend’s problems, but Head Dean wasn’t interested.

When my friend requested to be admitted to a ward, he responded “if we admitted everyone who came in here because they’ve been drinking we could fill this hospital three times over”.

At this point, my friend had had enough.  He got up off the bed, and said firmly but not aggressively, “Right.  You’re obviously not going to help me.  Could I have my clothes please?”

“Now calm down.”

“I am calm, I just would like to go.  I’ve come in here asking for help, and what you’re basically telling me is there’s nothing you can do and sending me off out to catch the bus home.”

The woman with the clipboard grips it more tightly, as if she’s about to get caught in a scene from a Bruce Lee film.  And who knows, maybe she might have been – after my friend decided to get back on the bed, Head Dean casually slipped into the conversation that he had a black belt in martial arts.

The veiled warning did not go unnoticed by me.  I couldn’t stay silent any longer.

“We’re hearing a lot from you about what you can’t do, how about you tell us what you can do for him,” I said.  “I’m getting the distinct feeling that if he’d come in here bleeding all over the floor you’d be paying more attention.  Can you prescribe him any medication to calm him down?  Is there any counselling available?  Can he be supervised over the next few days until he’s feeling safer?”

Suddenly, we start hearing the word “yes”, and my friend – much to my surprise – opens up about further damaging events in his life involving grief and loss that stretch back at least a decade.  Now Head Dean shuts up and listens.  It’s blatantly obvious now that my friend has been a pressure cooker, bottling crap up inside for years until today it finally exploded.

There’s promises of counselling referrals, and temporary prescriptions for anxiety medication, but he doesn’t get his overnight stay in the ward.  When I saw that things were going south, I offered – in front of the crisis team – for my friend to come and stay with us for the night.  They leapt on that opportunity like a Frenchman on cheese.

The ordeal was long and humiliating for my friend.  Despite clear signs of distress (including the clearest sign of all – an interrupted suicide attempt), he was treated like a middle-aged, middle-class drunk who just needed to get his act together and sort his shit out.  The phrases “harden up” and “get over it” were not used, but they may as well have been.

The follow-up care over the next few days was even worse.  Called by different staff members who seemed to have little knowledge of my friend’s case, and one who expressed surprise that he didn’t know where the counselling centre they’d referred him to was, and asked him to look it up in the phone book because she didn’t have the details.

The nail in the coffin was a follow-up call after the weekend from Head Dean, after my friend had managed to get himself in touch with a GP and a counsellor (all on our own organising, without any help or referrals from the crisis team).

Head Dean’s softening in attitude disappeared on the follow-up call, which ended with my friend hanging up.  Why did he hang up?  Because when he said to Head Dean, “I get the feeling that you don’t actually care whether I kill myself or not”, he answered: “I don’t.”

My friend is on the road to recovery now, and has started to address the melting pot of issues that have gone untouched for many years, but it’s no thanks to our experience with this particular crisis team.

Head Dean had volunteered while we were at the hospital that he’d been working in this field for nearly twenty years.  I’d venture that’s been about nineteen years too long.

Compassion fatigue (I’m assuming he had some in the first place) is the most insidious illness that a mental health crisis worker can have.  Those who don’t care about what happens to the wounded people that come through their doors have no place working in an emergency room.

This isn’t an episode of “House” where we can laugh at the funny quips from the rude doctor.  It’s real life.  And death.

19 comments on “Crisis teams: the bad

  1. [...] chronicled a good crisis team response and a bad one over the past few weeks, I’m going to conclude this snapshot look at the state of our mental [...]

  2. Sandy says:

    No surprise ive seen it myself an exhausted psychiatrist that would do just about anything to get you out of a&e so he can go back to bed…i can see both sides but as you say once they loose their compassion you are just another number..does anyone support them?just wondering..

    • James says:

      All health professionals are made accountable for their own practice, Sandy – it is their responsibility to ensure that they are fit to practice… Some do a much better job of it than others! There are some improvements but we still fight with the mythical notion that the medical profession are ‘beyond’ reproach… My late Dad was of the generation where he would all but pull his ‘forelock’ whenever a Doctor spoke to him – and when, as a nurse of many years experience, I would tell him some stories about the doctors mistakes I’d witnessed, he was mortified!

      I will always remember a friend of mine who suffered from depression telling me that the psychiatrist he was sent to by the health service would often nod off while he was ‘in session’. (Imagine how much he was getting paid for THAT service!) But the final straw was when my friend had to actually wake him up and ask him if they had finished. A little bit funny as yet another ‘tale’ of a failing mental health system – disgusting from the perspective of clinical practice!

  3. william wallace says:

    I should start by giving the good news. One’s depression not a sign
    of weakness be rather that of strength. EXPLAIN ?. One’s MENTAL
    depression comes from the stage of one’s brain development ( the
    good news) those suffering depression in the majority are at a very
    advanced stage of brain development // thus A depressive state…..
    ( such depressive state comes via chemicals as introduced by one’s
    brain // not to harm a individual but aid them through the final stages
    of brain development. One way (the best) in dealing with depression
    is not to try to escape it but rather to embrace it / in doing so one will
    find it be rich in its STRENGTH / learning depression very comforting.

    The warning with that is don’t get too attached to depression as the
    time will come that you no longer need such an aid in your life / thus
    the time come when depression but fades away as a distant memory.

    It can have a funnier side if one become so attached to (depression)
    (when it starts to fade as it will as must being natures way) that they
    then go to the doctor and complain that their depressive states are
    leaving them thus now concerned in their becoming // undepressed.

    The point being embrace depression feel the strength of its comfort
    yet understand one day you must be prepared letting go / as you no
    longer need its comfort /strength in taking one through a dark period
    of life // a period as leading unto the ultimate stage of Enlightenment.

    WHY ? should depression hit some not others. An developing brain
    in norm is at a pace it causes little concern. Yet with some it can go..
    through dramatic periods of tense pressure change ( thus bringing a
    a response from the brain in a chemical aid in causing the depressive
    state / thus to aid the individual through the changes // thus such the
    depressive state introduced is a aid / not handicap to the depressed.

    Thus understand and enjoy such stage of depression / that in finding
    themselves in // have heart that your going through such a advanced
    stage of development. Understand your depressive state is but a aid
    in your changing development / embrace your depression and ENJOY.

    Look at it as repairs as extentions unto ones home // some people its
    just a new carpet in the living room change a light bulb /in replacing a
    washer in the tap. Yet for those with the deep states of depression its
    being that much more // all the house rewired / new roof // everything
    being replaced by the most modern means. Thus you go through an
    testing time living in a home where so much work in progress /thus as
    the brain is making so many changes building new connections / it be
    a time of confussion great confussion yet when the changes be made
    you are going to have a home to be proud of / being worth every tear.

    The ultimate stage of one’s development as a human being is to turn
    the senses inward thus in bringing in an unfolding of the spiritual self.

    Throughout the history of humanity there be spiritual teachers /among
    such be the “Teachers of Teachers” presently the teacher of teachers
    is Prem Rawat / thus all human life is blessed in having an guiding light.

    On PC search put (words of peace) on site a selection of videos which
    Prem Rawat explains meditation / in one turning the senses inward in a
    unfolding of the spiritual self. Not of beliefs. Not of ideas. Not an heaven
    a paradise that beyond the clouds // but in having very practical spiritual experience that brings a clarity of understanding. WHOM AM I?. WHATS
    THE PURPOSE OF LIFE ?. IS THERE A GOD ?. IS THERE A HEAVEN ?.

    Human beings have been on the road toward enlightenment for an long
    long time. it having been a hard road such one can’t deny // yet its end
    brings such reward which beyond measure thus continue to be of good
    spirit // with such development of the brain comes understanding of the
    journey // with such spiritual growth in experience comes enlightenment.

  4. As a mental health professional of 30+ years, I’d love to be able to refute all, some or even any of this all-too-familiar tale. Sadly, it’s not an exceptional situation by any means. And yet, whilst not wanting to appear to be defending the indefensible, I do want to say that I have seen some pretty amazing, altruistic, humanitarian work done by some extremely talented clinicians. However I’d probably agree with the remarks made by Paul. Clinical supervision is something that all mental health services insist is an integral part of the support offered to the front-line clinicians – but regrettably, I haven’t worked in a service where it has never been made mandatory.

    Some professions take to clinical supervision eagerly, with enthusiasm, willingly – even (heavens above) PAYING for it themselves – most mental health services will contribute by allowing/encouraging clinical staff to attend their supervision in work time. But other professions (and I’m ashamed to say, the bulk of my fellow nursing fraternity is one of this ilk) seem to relate professional supervision with some kind of performance management. With this perspective, clinical supervision is tantamount to punishment. When you add to this mix that the types of clinical supervision and the skill level of the individuals offering it vary, it’s not hard to see why it is a very hot, moot, confronting topic in our clinical areas.

    Over-worked staff, under-funded services, the stigma attached to anyone having to attend a mental health service, outdated, impractical and sometimes just downright ugly and jaded environments are all ingredients which make the final product from this disastrous cooking pot more than just a little unpalatable. We all know that mental health is the Cinderella of health services… it’s not glamourous or sexy like paediatrics, or oncology – there are few (publicized) miracle stories like in cardiac and Emergency Department work… and I say publicized, because we clinicians DO see miracle stories from time to time (and not as rarely as you might think!) But the media don’t (want to?) see the magic of recovery from mental health… just picture the headline… “Man Previously Suffering from Bi-Polar Returns to Full Time Employment” “Mother of 3 Finds She Can Manage Housework and Schizophrenia”, “Teen Returns to Full Time Studies in Spite of Psychosis”… Nah, it’s not attention grabbing enough, is it? “Psychotic Man Murders Mother of 3″… “Bridge-Jumping Suicidal Woman Identified As Mental Health Patient”… Perhaps you can start to see where the on-going stigma and discrimination comes from?

    I’m so sorry to hear that your friend experienced the worst side of the mental health services. I’m so pleased that he was able to find the personal strength to focus on his own recovery and start to make that tremendous journey to wellness, again. And I’d just like to say that, in spite of some of the worst of the worst, there truly are clinicians out there (should that be “out here”?) who pitch their whole life’s work at achieving what Carl Rogers so deftly identified with a single phrase – unconditional positive regard for the people we work for… (and I don’t mean the system or the hospital health managers!)

    • Hi James, I would be more than happy to tell the miracle stories you refer to in your made-up headlines. I know there are good people out there in the system (I told a ‘good’ story last week), but care is so inconsistent across the country and if these postings can bring out issues that need to be resolved, as outlined really well in your reply, then I hope that someone will take notice and do something.

      • James says:

        It’s great that you’re putting these stories out there, Chris – and I totally support your blogs because I concur 100% with your optimistic objectives… i.e. that ‘someone will take notice and do something’. But from my experience it’s because these incidents come about due to such a hotch-potch of different issues that these difficulties are so easily swept under the political carpet. For instance, as a clinical nurse educator in mental health, I constantly struggle to come to terms with the change in nursing training. When I did my training to become a psychiatric nurse (in the dim, dark ages of the 80′s) we spent 2-3 years learning the tools of our trade. Now student nurses are lucky if they get 8 weeks (theory and clinical combined). The chronic nursing shortage (which I believe is more about funding than the numbers being trained because there seems to be plenty of students coming through the system) means that less experienced nurses/clinicians quickly rise to senior positions, thereby making clinical/management decisions they don’t often have the necessary experience to make. Politicians who make lots of noise about de-stigmatising and improving service delivery but then actually do very little about it, once in power. And as much as I hate bringing it up, cos we know it’s rarely about money (if it was, there’d be so few staff doing mental health work) but the pay and conditions for mental health clinicians (and especially the nurses) are dreadful, let’s face it. Nothing glamorous about it. Fines for mental health patients staying more than 24 hours in an Emergency Department which ultimately means that the pressure for beds is the governing factor in whether someone gets a bed and not, as it should be, the acuity of the person’s condition. An ageing workforce. There are so many different facets to this problem that’s easy to see how it simply overwhelms governing bodies. So they end up doing lots of ‘projects’, publishing lots of papers with fancy titles about “where to from here” but in fact, can make only small, measured changes to the outcomes. And when you’re the carer of or close friend of someone suffering within the system, none of these things really matter, in fact they all seem trivial. Because you just want your loved one helped – and now. Trust me, Chris – sometimes even from the inside it feels like we’re all versions of Alice at the Mad Hatters tea party.

        • Thanks James. It’s really tricky when certain things are just as broken on the inside as the outside.

          • James says:

            And this is why, as you and I have both reflected, it’s so important to give at least as much (if not more) attention to the things that are going right, whilst still unfailingly confronting inadequacies in our medico/political system. Sports coaches are doing this now, using the cliche “what you concentrate on, you get more of…” Mental health clinicians are TRYING REALLY HARD to do similarly by developing (please excuse the jargon) strengths-based, solution-focused, consumer-driven recovery models. But change can be frightening for some and progress is slow. Could it really be that it’s as simple as the words of that very old song by Johnny Mercer – “you’ve got to accentuate the positive, eliminate the negative, latch on to the affirmative and don’t mess with Mr In-between!” I believe it very well might be – but then what would all the politicians have to ‘sell’ their parties with…??? :-)

  5. Paul says:

    This is a dreadfully upsetting story, and your friend is lucky to have someone as switched on and empathetic as you in his life.

    The practitioner in question could very well be failing to do something that is drilled into counsellors and therapists: regular, ongoing, well-managed self-care.

    Without defending him, I’ve seen first hand how it is very easy to get caught up in your caseload, and in an effort to cover off all the bases and not miss anything it’s all too easy to slip into bad habits, become fatigued, bitter, cynical. He let it go WAY too far by the sounds of it, and that is a true tragedy – I doubt he was receiving adequate supervision (if he was receiving supervision at all – regular supervision is required in order to be an ethical therapist).

    Someone who could obviously have been incredibly useful to those in need has rendered himself professionally impotent through not attending to his own needs, I suspect. Again, I’m not defending him as I deem his behaviour in your friend’s situation to be truly appalling, and worthy of nothing but contempt, however I know how one’s attitude toward one’s clients can become skewed, slowly and insidiously.

    Or he could just be a useless plonker totally unsuited to the profession.

    • Hi Paul, at times I thought we were making a breakthrough and that maybe he was trying the ‘tough love’ approach because he genuinely thought it would work with my friend, but in the final analysis – particularly in the followup care – I think it was just compassion fatigue. Still not good.

  6. Jose says:

    I suffer from lifetime clinical depression and have been hospitalized twice – yes – I admit due to suicide attempts. The mental health “system” in the U.S. is disgraceful, degrading and controlled by the mighty dollar. It becomes worse when you use your mental health benefits through your private health insurance which they make it near impossible to be admitted unless you have a gun in your mouth. If you are admitted, then the insurance company’s “paid off” psychiatrist does everything possible to get you out of the hospital. Your inpatient care becomes nothing more than expensive very brief baby sitting with very little help.
    You, the patient, has to then sort out copays, deductibles, appeals of denied services while in a distressed state of mind. Once you’re discharged try to get an appointment with a Psychiatrist – it might take weeks. When you see one finally, its a 15 minute q&A session, a prescription is written and off you go – that’s it – then they refer you out to a counselor. Most counselors don’t like to take “at risk” patients so then the hunt begins to find one who does. You feel frustrated, passed around and seriously not cared for which feeds into your depressed state. Your friend is extremely lucky to have you, he really really is.

    • That paints a very bleak picture, Jose. I think one thing that seems to be common to our countries is risk aversion – not wanting to be the last professional to have seen someone in the event they complete a suicide. Yet the very business of looking after people is fraught with risk – would doctors refuse to see someone that has a brain tumour, cancer or diabetes?

  7. Patrick says:

    Has your friend laid a complaint about Head Dean… that man shouldn’t be working with ill people. If I had come across him I probably would have lost my wick and screamed at him. I’m really glad you were there to support him. Mental health workers have real problems when faced with what seems to e a dual diagnosis.

    • A complaint was laid, but unfortunately it’s one of those classic “he said/he said” scenarios. His supervisor spoke to him and then rang my friend to say “that’s not how he recalls the situation”.

      He’s glad he made the complaint though, as the hope is that enough of these scenarios (which I’m sure there have been/will be more of) will get to a point where they’re impossible to sweep under the carpet.

      • Patrick says:

        where’s the like function when you want one :)

      • James says:

        Chris, can I also comment that the “I don’t care (if you suicide or not)” comment may have actually been a very badly delivered clinical strategy which is common in mental health services and when used appropriately can actually SAVE lives. The bottom line is that we cannot ever, ultimately stop someone who is 100% intent on killing themselves. These are the people who complete suicide and, as our media tell us, there are ever increasing numbers of them – especially the teenage victims of bullying.

        Most mental health services work with caseloads which include an incredibly high percentage of people (mostly women) who have Borderline Personality Disorder (BPD). And one of the ‘strategies’ used when working with people who have BPD is to (respectfully) return the responsibility for staying alive to them. When this strategy is poorly understood or clinicians are simply overwhelmed by how often they have to use it, it disintegrates from a specific, well-researched and respected clinical intervention (wherein the individual’s support networks are well engaged and informed) to a burnt-out cop out.

        Let’s hope that the clinician concerned at least THOUGHT he was being strategic…?

  8. Ashley Cobb says:

    you are a good friend, and those people involved should all be ashamed of themselves. no excuse for compassion fatigue. you do that job, do.it well, if you cant, get out

  9. Barbara says:

    This blog had me in tears. While I’ve never made a suicide attempt, I did have severe depression for four to five years in my early 20s. Every ‘professional’ I saw during this time had the same attitude….that I was doing this to myself. That it was my fault that I hadn’t recovered. And that they didn’t really care whether I did or not.

    I felt like I was screaming for help the whole time; they didn’t seem to understand that I would do anything not to feel that way any more. I did every therapy task they set me, I took every drug I was given. Unfortunately, none of the treatments offered were right for my particular situation. But in the system in this country they prefer you to fit into their model of treatment, not tailor their treatments to suit you.

    I am now very well (a state which I achieved with no help from the mental health system in this country) and completing my Masters in Psychology. I only hope more like us can speak out about our experiences, and help prevent others from going through anything similar in the system. I’m so glad you were there for your friend in this case, many like me go through this alone.

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