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.”
Brief encounters
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.”.
Banal advice
“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.”
purplepersuasion 
Thank you for this Charlotte. What is described is not therapeutic- (and is at times potentially harmful) but merely community surveillance. It would appear that it is even failing at that vey basic level too.
It feels wrong to ‘like’ this post, but I like that you’ve written it more than what it tells us… unfortunately good intentions don’t always translate into good care, whether in the community or in a hospital setting, and all too often it’s just the luck of the draw as to whether or not you get the help that you need 😦
Can very much sympathise with the concerns people have about the “lucky dip” concerning staffing. I used to get very distressed before home visits from HTT , hoping it wouldn’t be certain people who I knew would wind me up and make me feel worse. Certain members of staff (usually male nurses, I found) were sympathetic and friendly. A lot of the women behaved absolutely abysmally and to were downright rude, to be frank. They used to dash in and dash out (after spending 2 minutes watching me swallow a handful of medication I didn’t want to take) – occasionally I got a perfunctory “how are you?” followed with the manadtory “guilt trip” abouthow busy and stressed they were. I was with them for a little over 3 months and lived with the constant threat of sectioning for this entire time, without really knowing why. I was wholly unsupported, scared, and bewildered. On the whole, it was a horrific experience and has left me with a plundering faith in all these kinds of “co prehensile community services”.
The last sentence should have read “comprehensive community service”…!
This makes for rather sad reading. There are some excellent nurses within these teams and others who are more challenging. I would hate the “good guys” to feel tainted by one overall brush. It is the repeated question of “what help do you want” that I found so hard when I was unable to barely even speak with distress. It seemed that if I couldn’t answer that question there were no suggestions forthcoming as to what might be helpful.
It was interesting to read of the genesis of these teams. I can’t fault the model but I suspect the reality has drifted a long way over the last 15 years or so. So often, my family weren’t around when they called. I had no idea HTT might have any interest in the very difficult circumstances within my household. If I felt that HTT as planned was available I think I might be quite supportive of them.
You say this is not based on “proper” research. I wonder if that could be done. This is an excellent article and would be worthy of more empirical back-up.
It’s true, some of the nurses were great but I agree they don’t take a lead, maybe because they don’t want to be seen as imposing, maybe because there is no effective intervention they can actually deliver. The nurses knew that tension within my family was one of the key stressors, but nothing was done about it beyond giving me a couple off psychology sessions, the point of which eluded me. My other major stressor was feeling like nothing would ever change and quite frankly not starting me on the new med that had been prescribed for me just reinforced my view that nothing would ever get better.
My experiences have uniformly been negative so I now refuse to work with them. The only exception is when I self refer to the crisis house as they are the gate keepers but do not actually provide care at the service.
I think there generally are issues with home treatment teams, not just in my borough. I have used three teams (North and South in my borough and one in a different borough) and they have all been useless. They often don’t turn up, expect you to wait for hours to return a call and give the same useless advice. When they do come round all they do is ask if I’m eating and if I have any immediate plans to harm myself. As long as I’m not going to kill myself it seems like they don’t care. Sometimes they make comments about me being “unkempt” which feel like a judgement. I know I don’t do a very good job of taking care of myself when I’m severely depressed, that’s why I need extra support!
I understand there are a lot of people in need but a five minute check to see if you are alive is box ticking not treatment.
“Unkempt” is rude, IMHO. What’s wrong with gently saying that you don’t look you’ve been looking after yourself? That’s a valid point to make because it probably reflects your state of mind. I wish people would be more careful with their language 😦
Exactly. It’s not just what people say but how they say it. I am well aware if I haven’t showered in days and I don’t hide that fact (as if I could with greasy hair and the same pyjamas as last time they came round!) but using words like that just adds to an already negative self perception.
With all due respect to both Lauren and Charlotte, “unkempt” is more than rude and carelessness with diction. For a depressed person, it is dangerously unprofessional and outrageously ignorant in a supposedly “trained” mental health care deliverer. Not taking showers and wearing the same dirty clothing is an obvious clinical sign of mood distress, signalling the need for a clinical response. These personnel clearly need thorough retraining, or dismissal as unsuitable for their posts.
Hello. I have been following your blog for about 6 months. Thank you so much for writing it. I am about 3 weeks post discharge from my first 3 week voluntary hospital admission (aged 38 following life long problems ? Diagnosis) Before I was admitted I was under a crisis team for about 2 weeks and found them very useful, as before I just ended up in a and e, and then they got fed up of me and referred me to crisis . They got me a drs app within 4 days. I have appreciated the offer of chat / advice 24 hours a day and so has my husband. Tomorrow I have my first psy dr community so I hope my I cmht will be just as useful . wish me luck.
I can imagine that if you have been thru the whole cycle lots that you would perceive the “chat” option as not so helpful. Xx Charlotte
Hi from one Charlotte to another! No, the chat is useful – but it’s not enough. If anything it validates my feelings and so consolidates my belief that something needs to change only – there isn’t anything to effect that change. CMHT docs, like the rest of it, are part of the lottery. I think I’ve had six over 20 years, not counting emergency duty psychiatrists, and they have varied from the abusive to the fantastic, via the uninterested. So yes, I do wish you lots of luck! All the best x
Your post title just popped out at me as I was given this advice not so many weeks ago by someone from my HTT. Sat at my kitchen table saying “aren’t they [your children] good? How sweet!” as my youngest stressor made 8 different demands of me in the space of 5 minutes and I sat there in tears (suicidal and self-harming). I had hoped that I’d had a bad experience but the service on the whole was good. I am sad to read that bad experiences with HTT seem commonplace. It was my first experience with HTT, awful in comparison with my previous inpatient stay however my family circumstances made it preferable although infinitely more difficult. If it wasn’t for my own tenacity in insisting on changing medication, it most definitely would have contributed to a decline in my MH (there wasn’t much further to go!). To say I was shocked by their approach and attitudes would be an understatement. As soon as I was no longer ‘desperate’ I was discharged. Then left for a whole month with one CPN visit and again I had to insist on seeing my psychiatrist, but not before being told by her secretary that I “shouldn’t need a medication review now” – I had said nothing about medication. One meltdown later on the phone to her manager and I managed to get an elusive appointment. My psychiatrist proceeded to breakdown on me when I eventually sat in front of her. Talk about mental healthcare in crisis.
My depressed/creative brain cobbled together a short poem about HTT and diazepam whilst I was in crisis, I won’t link it as it would be rude to crash your post but it’s on my website if anyone wants to read. Just search through my ‘mental health posts’ to skip my card therapy. Hubby finds those bits boring. My children ARE sweet too, in case anyone thinks I’m a ratbag mother, but when resilience is zero I need Mary Poppins to take over. End of rambling.
Thank you for the post Charlotte, we certainly do deserve better than that. I wish I had a magic wand.
Your blog says it all Charlotte, crisis/HTT are no longer fit for purpose. I dread calling mine and prefer to use the samaritans who at least treat me with dignity and respect. My local HTT are awful, they told me the last time I called that they couldn’t help me, I had tried tea, bath and benzo’s.
Thanks for such an insightful blog.
I’ve stopped phoning them as I invariably feel worse afterwards. Last time I called I had been getting steadily worse for days, my cpn wasn’t getting back to me and I had done everything in my power to distract myself to no effect.
I paged them and they didn’t reply for three 1/2 hours. Then I got a three minute phone call where the person said, ‘well you know you’re quite often emotionally unstable.’ That sounded like a judgement to me. I told him I was absolutely desperate and his response was ‘I’ll send a fax to your cpn.’ This was on a Friday evening and clearly the cpn wasn’t going to contact me til at least Monday so I was left on my own, feeling suicidal, for the entire weekend. They were so dismissive that I felt I wasn’t able to contact them again.
I know the local team has been told to concentrate on s136s at the expense of their usual work but if they helped people when people needed help there would be fewer s136s for them to deal with. That’s just common sense.
I’m terrified of phoning the crisis team now as almost invariably they’re useless and if they are any good its the one person speaking to you that makes a connection with you rather then the team being good. I only ever phone them now when my mate tells me I have to because she’s reached such a high level of concern. It shouldn’t be like that.
(and yes I’ve had the bath, brew and benzos thing several times)
Thanks so much for bringing this issue up. There’s no regular support available to me from the mental health team due to waiting lists, so I’ve had to contact the crisis team on numerous occasions because without treatment and support I’ve been going downhill. “most people under HTTs are desperate and/or suicidal and, having worked through their own self-care options, are looking for much robust support” is a pretty accurate summary. Much of the ‘advice’ is cups of tea, baths, going for a run …. none of these options are tailor-made to the person (eg, I’ve already had 6 cups of tea that day… my flat doesn’t have a bath… and I can’t have a bath or go for a run anyway due to heart condition and ME).
My local crisis team only works office hours and has 2 members of staff a day. The team only has two dedicated staff members, and the others are ‘borrowed’ from other teams. When you’re referred it’s very unusual for them to be able to see you on the day of referral. Out-of-hours there’s one crisis nurse covering the entire county, and can only offer telephone support.
Unsurprisingly, the local crisis team has been in court recently after a man took his own life. His daughter had phoned them for help and they’d told her to ring back in half an hour; it was too late.
I’m personally feeling quite upset with regards the crisis team. They’re the only option open to me (every other place/person I go to asking for help refers me back to them – GP, Samaritans, Mind, friends/family) yet all I get is patronising advice. And then when seeing my psychiatrist she criticised my “excessive” use of the crisis team (which obviously I wouldn’t have to use if I had any treatment/support), and suggested that when I “feel a bit upset” I respond “like a normal person” by for example “distracting yourself” or “phoning a friend”. As I only phone them when deeply suicidal and after having expended all other options I could think of…. that was a big kick in the teeth.
A really good post (as always), I’ve become disillusioned with the crisis team, earlier this year I was with them, and then went into hospital (which didn’t help), and then once I was out it felt like they were in a hurry to discharge me, even though I told them I was still feeling suicidal. I felt I was no longer worthy of their time, and that they felt I should just be getting on with life.
There are good nurses out there, but they still give you the ‘what have you got planned for today’? then suggest you see a friend (often there was no one around to see), go for a walk etc etc. I find it so frustrating that when you are really as low as you can possibly go you can be made to feel such a waste of time and space.
I feel the problems with the HTT’s (and many other professional mental health practitioners) is a lack of respect for the patient. Most patients are quite intelligent and knowledgeable about their own needs, and are very aware of the treatments and medications that should be available to them. The role of the HTT ought to be to facilitate those remedies, not to block them with a patronising “mother knows best” response. The thing they seem unaware of, is that mother does *not* know best, unless and until mother has listened very carefully to what the patient has to say. If the person is too distressed to speak coherently, a competent professional can still obtain the necessary input through body language and patient, delicate, and *empathetic* enquiry. Switching personnel as if anyone will do for the task, is a further sign of disrespect for the patient.
Thank you so much for discussing this. My HTT has been ‘re-modelled’ and is now called an ‘Access Team’. This means they don’t even do home visits, all they provide is a phone number to call – less use than ringing Samaritans or other charities. They provided no intervention at all when I was suicidal – just rang me back a couple of hours after a desperate phone call to see whether I was still alive or not!
My daughter just had horrendous experience after a significant suicide attempt. Sent home with a scribbled illegible scrap of paper with crisis teams telephone number n told to call if she had those feelings again to ring one of the numbers. She has been badly let down by system and us as a family have been left unsupported to get her through this and keep her safe and alive. A thorough review of suicide prevention and crisis interventions are needed throughout the UK, we are in Scotland so sadly this is not just localised.
Hi Heather, I am so, so sorry that you have had such an awful experience. That’s one of the things that prompted me to write the post: the same poor practice and the same inadequate advice wherever someone was tweeting from. Really worrying 😦
Great post, Charlotte,
I just want to expand on what I told you about my experiences.
I had lost a close friend who had killed himself, and was getting over major surgery when I started to feel depressed. Over the next few months, I stopped going to work, lost a lot of weight and was getting desperate. The psychiatrist brought in the Home Treatment Team. On the very first visit , rather than talk to me or listen to what had been happening, they talked about the rules of the team and how the visits would be arranged. I was meant to get four visits a day, but was told that the second day would be reduced to three, the third day to two and so on.
I felt like an inconvenience to them and also felt their attitude was appalling. At the time I worked for Social Services and they seemed more interested in this than anything I was trying to say. I didn’t trust them enough to tell them about my friend, or the fact I wasn’t eating/sleeping.
When the visits were at one a day and coming to an end (was I cured?) my mum phoned the psychiatrist. He did a home visit along with my GP and social worker and I was sectioned and taken into hospital.
I think these teams should be approached with real caution unless big changes are made to how they operate.
Thanks for highlighting this, Charlotte.
Very interesting post, thank you. The sense of frustration is shared by many who work within a CRHTT, I can assure you, having worked there.
Problems include:
– being under-resourced from the get-go, hence never being able to live up to the original expectation that more than one visit/day can be provided, and contributing to visits being brief.
– monthly targets set by local commissioners which meant a certain number of ‘patients’ had to be under the team at any one time, which often caused a focus on the ‘worried well’, rather than those whose level of illness would have otherwise required hospital admission; the original premise of a CRHTT.
– lack of psychology resource.
And many more.
Am pleased to read the positive comments, and empathise with the negatives.
Re: help with benefits. I had extensive help, though I was kept on jobseekers for a while instead of being put on ESA, which would have helped with the stress of the situation I was going through. From what I’ve read it seems there is a real mixed bag when it comes to receiving services perhaps between regions as well as with individual members of staff. At the time I was receiving help some of my fellow patients were aided by a complex needs team in which three days a week patients visited therapy to work through their problems. It sounded difficult and many people did not finish the course.
Merseycare NHS Trust doesnt even have a CRHT team any more, and forgot to tell the patients about it. I have no idea what their crisis treatment options are now despite trying to access it for 6 weeks. I have heard from service users not staff they have “stepped up care” now that only operates in office hours but am not sure how true this is.
Completely agree with everything said. Thank you for vocalising all this. Am under HT at the moment for the second time… while they are lovely I don’t find them remotely useful. They don’t even ask about my level of risk.
At the end of each drop in they always say “will you phone us if you need to?”. I always tell them that no, I won’t. I have social anxiety and won’t be able to use the phone in a crisis. Then they tell me to try harder to phone them . If trying harder worked I wouldn’t be under HT to start with. It eventually ends with them saying “well, you have our number, please phone us…”.
Like, I’m not being difficult here. I have problems asking for help as part of my condition – which they are actively adding to. Surely they could have come up with some practical advice or an alternative by now. I can’t be the only one with this difficulty.
Oh the phone thing REALLy gets me, because I would say that 9/10 of the people I’m connected with online find phonecalls incredibly hard, and increasingly difficult with increasing distress. Which is exactly the point they say, “You’ll have to phone us if you want support” – argh!