Last week a paper was published in The Lancet Psychiatry entitled ‘Safety of patients under the care of crisis resolution home treatment services in England: a retrospective analysis of suicide trends from 2003 to 2011.’ The authors, among them Professor Louis Appleby, former national director for Mental Health in England, found that average rate of suicides (14·6 per 10 000 episodes) under crisis care seemed higher than the average rate of suicide among psychiatric inpatients (8·8 per 10 000 admissions). Cue another much-needed discussion about Home Treatment Teams and what they can realistically offer.
I first heard of Home Treatment (aka Crisis Resolution) Teams several years ago and I thought the idea was fantastic. I am a big believer providing community services where possible, so I was all for the provision of intensive treatment at home instead of hospital admission. Yet by the time I agreed to Home Treatment earlier this year it was after months of resistance and was a reflection more of my utter desperation than any optimism about the service. Why? Because I so rarely heard anything good about HTTs and much of what I had heard was shocking. As I said to Professor Appleby on Twitter, “A child could dispense most of the ‘advice’ I have seen offered”. He called this “a serious criticism” of what was “meant to be a highly specialised acute service”, and indeed it was. Comparing the intention behind the setting up of HTTs with the current level of service provided to those in acute distress leads me to believe that the intention behind these teams has become very much lost in translation, perhaps dangerously so.
Let’s rewind to when these teams were originally developed. In 1998 the Sainsbury Centre for Mental Health produced a booklet sharing best practice based on the Northern Birmingham model for Home Treatment. The model involved a Team Manager, eight frontline nurses with varying degrees of seniority, two Approved Social Workers (or AHMPs as they are known these days), two unqualified Health Care Assistants, a part time Clinical Psychologist, and administrative support (what leaps out at me here is that the team contained no doctors).The aim of the team was to form a therapeutic bond with the client and relieve the burden on the service user’s family by providing both the individual and the family with “information, support, guidance and counselling”.
By 2001 the Department of Health’s Mental Health Policy Implementation Guide made it clear that HTTs should be established and that they should work only with “an acute psychiatric crisis of such severity that, without the involvement of a crisis resolution/home treatment team, hospitalisation would be necessary” – in other words as a direct alternative to hospitalisation. The focus would be on diffusing an individual’s crisis through assessment, planning, intervention and resolution. It was envisaged that intervention would be specific and intensive, potentially requiring “several visits a day” in the early phase, and would involve:
- Immediate, 24 hour access to medication
- Practical help with basics of daily living (such as help with benefits, housing, childcare, etc)
- Family/carer support (including education and practical support)
- Therapeutic input, including: problem solving; stress management; brief supportive counselling; help to maintain and improve social networks
- Development of a relapse prevention plan and a crisis plan
- Provision of respite care if needed.
I threw the issue of HTTs/CRTs open to my Twitter feed. I’m not pretending this is in any way “research”; I simply asked people to share their experiences. I’m not going to use anyone’s Twitter names as some people needed to remain anonymous so anonymity for everyone seemed the simplest way. A sizeable minority found their HTT invaluable and were full of praise; others found parts of the system helpful (e.g. the liked the HTT doctor but found the nursing input intrusive, disliking HTT practice but still preferring that to admission).
Overall, the message that stands out is that HTT is no longer delivering the intervention that was once at their heart. Nobody who responded mentioned help with benefits, with childcare or other practical support. All too often they reported being offered banal stop-gap measures, such as making a cup of tea or having a bath as a “distraction”. Little medication advice appears to have been offered beyond taking a prescribed benzodiazepine. Many people feel insulted by these suggestions; most people under HTTs are desperate and/or suicidal and, having worked through their own self-care options, are looking for much robust support and advice. But how could intervention along the lines of the original model be delivered if staff are ringing or visiting for just five minutes a day as individuals report? Another widespread concern is the large number of staff in teams. A service user may have a named lead worker, but this is of little use if they never see the same worker twice. For some people having to tell and retell their stories to different workers on different days increases their distress and the staffing “lucky dip” can make it impossible for therapeutic relationships to be formed.
Can HTTs still work in the current funding climate? Well, clearly some teams are getting it right in some areas. But they appear to be in the minority and the same problems are occurring up and down the country. “A brew, a bath and a benzo” is not intervention and without intervention people feel pinned in place rather than supported, monitored rather than helped. The purpose of the team seems to be little more than a method of ensuring service users are still alive. Little is done in practical terms to resolve the crisis so it can feel as if the team are playing a waiting game, keeping the individual on until they either require admission or spontaneously improve. The Lancet Psychiatry study concludes that, “the safety of individuals cared for by crisis resolution home treatment teams should be a priority for mental health services.” That can’t be done in five-minute consultations with little or no therapeutic value. I think we deserve better than that, and I believe that we deserve our “serious criticisms” to be noted.
The positives/mixed responses
“I found it easier to be honest with the HTT team about the severity of my symptoms.”
“Visited everyday Xmas Eve to New Year only contact I had with a person.”
“They were meant to come to an important appointment with me and forgot… but have also been excellent.”
“When I was unwell a crisis team visited me at home and it worked quite well. I would have hated hospital.”
“My HTT treatment in last 3 years HAS helped me stay at home so grateful for that, has varied, overall good, have most support.”
A number of responders voices concerns about the short of time HTT staff spent with them and felt that this was risky practice:
“When I needed to be in hosp HTT weren’t a good option. I needed/wanted 24hr care. HTT we’re very brief telephone conversations or visits and I often felt them to be more disruptive than therapeutic. I just don’t see how as an alternative.”
“Name HTT sort of self evident, but no! One visit and then phone calls at odd times, presumably to see if still alive.”
Concerns about risk
“I’m not surprised the suicide rate is higher under HTT treatment. Not sure about risk management.”
“Having a 5 minute chat with someone every day is never going to provide the same level of safety or support as good inpatient treatment. I always think HTT treatment for someone suicidal is Russian roulette.”
Lack of understanding of diversity issues
“I was told by a member of the HTT that my problem was being gay… lost credibility after that!”
“Being told off for not turning the TV off quick enough when they came (struggled to get to control because of physical disability).
(From someone whose trauma issues meant she did not feel safe alone with a man) “I’ve been suicidal & they’ve said ‘Well we won’t be able to visit today because no female staff’.”
Lucky dip staffing
“HTT positives: if you get same people they know you a bit more and can make realistic suggestions. Negative: don’t get same people. They can’t keep you safe, only make sure you are still alive.”
“So many of them hard to stay consistent. Also, they see you once, twice and then every time just assume they know you…”
“The biggest problem for me with HTT was being seen by different people, sometimes twice in the same day, having to repeat my story over and over. I found this made things a lot worse, heightening my distress.”.
“It felt like an endless round of tea making. I did not feel supported like I did on the ward.”
“I was given the ‘try a hot bath’ advice even though I had tablets in my hand.”
“Benzos & tea or distractions a big thing with our useless local crisis team.”
“Tea is awful. As are all hot beverages. And baths trigger me something terrible. I’m ‘difficult’.”
Having to be the “right kind of patient” and access the service in the “right kind of way”
“You have to fit in with their model – no flexibility. Out of hours response dismal – told to go to A&E or call emergency service.”
“Having what was actually bothering me completely ignored because it didn’t fit with ‘usual’ issues to name a few. Seriously, last time I was in crisis, took an OD, & hubby stayed up to make sure I was breathing as didn’t want HTT near me.”
“I found not being able to self refer a big problem.”
“I found they spent time only on what they wanted to discuss, and decided to reduce visits after day one. I was sectioned one week later.”
“In despair last weekend: called Mental Health, redirected. Called GP: closed. Called 111: told someone would call me. Received blocked call from MH nurse. She said someone would call me. >1h later blocked call from bad GP. Who then called back again & again. Called HTT on number GP gave and was told they would not speak to me, that I must call MH. Said I had, 8h earlier Told that I should go to Emergency Department. Said I could not. Had to find a way to say that I would find a way to be okay, or HTT would send police. Several days later, got to see my own psych. We discussed giving me “permission” to access HTT.”