Step by step and day by day: enter the Home Treatment Team

[TRIGGER WARNING: SUICIDE]

I’m not really sure what this post is. An update? An explanation? Perhaps it’s more of an exploration of what is happening to me right now.

Regular readers of my posts and tweets can hardly fail to have noticed that I’ve been struggling. Ever since Christmas I’ve been trying to pretend that I’m not in crisis, forcing myself to complete training, engage in activism or turn in pieces of work, as proof that nothing was really wrong. In terms of care I’ve been relying, as usual, on roughly monthly appointments with my consultant psychiatrist. A couple of months ago I was in such distress that he tweaked my antipsychotics up to the maximum recommended in a community setting. For a little while the dose increase seemed to help, or else my mood was boosted because my distress was being taken seriously. Either way, the improvement didn’t last.

The weekend of 15^th and 16^th of March I wept and wept. I confessed to my partner Tom that for the first time in years I did not think I could keep myself safe. I was rapid cycling, which is highly unusual for me, and the drops in mood were both sudden and severe. (This remains ongoing. This time yesterday Tom came in from work and noticed I was very quiet. My mood was low and I’d cried a lot in the day. During the evening I felt a shift, then pulses of genuine elation. By bedtime I was energetic, chatty and really wanted to stay up and talk. There was no reason for this change that either of us could discern.)

Back to that very difficult weekend, when thoughts of my own death and how I might achieve it were becoming very intrusive. Suicide planning had reached the level where I had reconnaissance missions in mind to ensure that I could die exactly when, where and how I chose. I was also aware of starting to think through practical arrangements for after my death. I did think of seeking crisis help but I wanted to see my consultant with all his knowledge of my history, rather than some unknown doctor on the emergency duty rota, only my next appointment wasn’t for a couple of weeks. I wrote Tom a list of ways he could help me at home until we could sort something out. The items ranged from the mundane to the critical and reflect my inability at that point to manage quite small things.

1)   Phone Dr X’s secretary and see if he is available to see me earlier

2)   Hide my meds so I can’t overdose

3)   Change the bedclothes because the duvet cover is beyond me

4)   Take away my bank cards so I can’t run away

5)   Buy ready meals so I don’t have to worry about what to make for dinner

6)   Book me a massage

On Monday Tom tried to find out Dr X’s availability but the admin staff didn’t seem to know and did not call us back as promised, so I emailed Dr X direct. He explained that he had limited time for clinical work due to other responsibilities but could offer me an appointment on Thursday, an arrangement that caused me to weep with gratitude. Tom came too and sat beside me as I described the rapid cycling, the depths of depressions and the brevity of the mild hypomanias. I told Dr X that I had no idea how to manage my condition any more. My self-management plan was based on mood states of weeks or months, not days or hours. I dared not try to correct the hypos in case I spiraled downwards, while very little in my armory of self-help techniques impacted on the lows. I had tried and tried, but I couldn’t do it any more. My life had become untenable. Something had to give.

“What do you think would help?” asked Dr X. “Or are you too confused to be able to say right now?”

We’d discussed a third medication at a previous appointment, but none of us had wanted to go down that road until we had exhausted the dose range of the meds I was already on. Now I thought it was time for another drug and Dr X agreed, although he wanted to discuss my needs with the lead pharmacist first. “And Charlotte, have you thought any more about the Home Treatment Team?”

I looked at Tom. We both had reservations. I’d heard many people’s experience of HTTs (aka Crisis Resolution Teams), and not much of it was very inspiring. Many people seem to have been offered pretty vacuous “advice” along the lines of, “Have you thought about having a bath? That would be relaxing!” or “How about making a cup of tea?” It’s amazing how often these suggestions come up, regardless of where in the country the service user lives. (It is also noticeable that staff rarely seem to investigate whether the person in crisis has fantasies about drowning. or has self-harmed by burning or scalding, before making these suggestions.)

Tom’s concerns were a little different. He knew from his professional life that HTTs can be quite large, making the chances of seeing the same person slim. He thought that might frustrate or upset me, especially if staff hadn’t read my notes before seeing me. There was also the question of geography. I can’t be seen in my home area because of Tom’s work, so I’m seen several boroughs away. This was fine when I only had Dr X or the team psychologist to see. But the distances were too great for home visits to be practicable, so the Home Treatment Team wouldn’t be able to see me at, well, home. I would have to come to the hospital instead.

I decided I didn’t care. I didn’t care if they might be rubbish. I didn’t care that I would have to go back and forth on public transport. Anything that might break the cycle had to be worth a try. Dr X said he would make arrangements and phone me that afternoon. He was as good as his word. By the end of the working day I had confirmation I would be taken on by the HTT, had spoken to one of its nurses to agree an appointment and blood tests, and had a recommendation for a new drug (carbamazepine) which Dr X was going suggest to the HTT consultant.

So far, the help of the HTT has been invaluable. Most clinicians have taken the trouble to read my notes before seeing me so I don’t have to explain myself all over again. I’ve been able to share the things I’m scared of, and have received emotional support. One of my fears was that I didn’t really need/deserve the team, that they would wonder why on earth I’d been referred to them. They have gently disabused me of this notion. I’ve been able to disclose some the things I have been doing to get my suicide plans in order and they have listened, without judgment, and asked how they could help to keep me safe.  No one has told me not to be selfish or to think of my children. They have sat and listened and been kind while I have cried and reminded me that bipolar is not fault. I have shared my worries that I might go into a mixed mood state or develop delusions again. “Don’t worry too much about going too high,” said my lead nurse. “We’ll keep our eye on that for you. We’re more concerned about getting you out of these horrible lows, so anything you can do to bring your mood up a bit, do it.” It feels like they have my back.

I’m attending appointments at the unit roughly every other day, although I’ll be attending both tomorrow (26^th March) and Thursday. Thursday appears to be case conference day, when I will get to meet to HTT consultant and see what he thinks of my blood results and Dr X’s med suggestion. The team are on duty 7 days a week from 8am to 10pm, and unless I’m going really high the quetiapine knocks me out between those hours anyway, so I’m unlikely to need the out of hours advice line.

Right now, of course, I feel great. How tempting it would be to tell the HTT that I don’t need them any more! It would almost be embarrassing to turn up in this jolly state. Of course they know about my rapid cycling, that it’s a big part of the reason I was referred to them. They won’t let me make any over-optimistic decisions in the grip of hypomania, even if I do feel a fraud. But then who knows how I’ll feel tomorrow? Right now it’s all about holding on, day by day, until I can try the new med; then it will be all about theHTT monitoring me as I adjust to that. Step by step. Day by day.

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