The response to the series from those who have experienced the system as ‘customers’ and those who have worked within it has been huge. The common threads among the frustration and anger at how people have been treated at the most vulnerable time in their lives have also included a desire for change; and to acknowledge the good, unsung work that gets done every day by mental health workers.
Where to from here? Well, we’re not going to save the world with this blog, but perhaps we can provide some points of discussion about how to move forward.
So, on with the five ways:
1. INTEGRATION, TRUST & LESS PASSING THE BUCK
In many of our stories, we’ve heard of buck-passing, a feeling from the patient that the crisis team’s attitude was ‘you’re not my problem’. There’s also a disconnect between what happens to a person in hospital and after they leave crisis.
This buck-passing doesn’t just happen from crisis team to patient, but also from within the medical system. The Berlin Wall between physical health and mental health creates huge problems.
“I’ve, on multiple occasions, had elderly people dumped on me by another team saying ‘they’ve gone nuts and therefore you need to fix them.’ And invariably these people had medical conditions that needed fixing,” George says.
“I’ve phoned teams back, for example, saying ‘if you had done some basic bloods, or even a urine dipstick, you would know that this person was septic. Sepsis is not a psychiatric problem, sepsis is a medical problem so I’m sending them back to you and you’re going to fix them’.
“And that invariably pisses them off, but there are some extremely lazy doctors out there who the minute somebody just starts talking to themselves, or ‘catching butterflies in the sky’, then they are some sort of mysterious psychiatric problem when it’s not, it’s a medical problem and you need to fix it.”
Ideally, treatment for physical and mental health issues should “walk hand in hand”, says George, but systems are not set up that way.
There may also be a lack of trust between crisis teams and the community services that they’re discharging patients into the care of.
“To me, it’s a sign of a dysfunctional unit that people are being held in hospital because there is an inherent distrust between the hospital-based team and the community-based team.”
2. ALLOCATE RESOURCES ACCORDING TO NEED
Of course, getting a bed in a mental health ward can be like negotiating your way to the top of a greasy flagpole in the first place.
The level of quality care you can expect from a crisis team in New Zealand is a real throw of the dice, and it often comes down to resourcing. This is not to say that the problem is one of money (there’s never enough money in the system), but that it isn’t being allocated fairly to areas of high need.
George has worked in teams that were well-resourced, and those that weren’t.
“It can be really dependent on district and management. One of the biggest stresses on anybody working within a crisis team is, do we have a bed for this person if need be? Knowing that you’ve got beds up your sleeve is a really comforting feeling.
“I have worked in a hospital where part of my daily job was to go round and see who we could boot out for the night. That’s cruel and that’s nasty, and sometimes people were pushed out of the hospital just so we could have one or two beds available if anybody needed them overnight.
“You might turn up to the Emergency Department and see three or four people in a night, but you might see twenty people in one night as well. Adding into that, the demographics of where you are makes a massive difference.”
The under-resourced hospital where George worked was in a low socio-economic area with a high concentration of people with acute mental illness.
“Unfortunately government funding doesn’t necessarily equate to that though, so I would have on average four or five new patients a day. And that, as a doctor, is extremely stressful because you never get to know your people, and that’s really, really hard.”
3. ROTATE CRISIS STAFF
“Yes, absolutely. They’ll have no sense of reality. I don’t think that’s a good idea.”
An opportunity for staff to rotate through jobs would take the pressure off.
“I think that would be very useful, just so people can have a grounding and see ‘ok, it’s not all like that’. The other reason you want to have this sort of rotation is so that people can understand what other services are available, so they can say ‘this is what we do on the ward’, ‘this is what we do in the community’, ‘this is what we do in a crisis intervention’, so everybody understands exactly where they’re standing.”
George was in a position where he was able to rotate through jobs and he found it very beneficial.
“I was very lucky, I worked in a position where I could have a very holistic view. I did lots of different jobs, so I could very easily know the difference between seeing somebody psychiatrically unwell on a medical ward, versus somebody in the psychiatric ICU, versus somebody in the forensic system. I understood how each of the systems worked, so I also understood what the limitations were and what I could push for.”
4. GREATER FOCUS ON STAFF MENTAL HEALTH
Dealing with acutely unwell people on a daily basis is a tough job, and the burnout rate is understandably high.
“I really think that the mental health of people working in crisis teams needs to be looked at very, very carefully, because when you spend all day looking after people in acute crises, if somebody comes in, you know, a little bit upset, sometimes the comparison with either what you’ve done earlier in the day, or the comparison with your own mental health issues can be difficult to deal with and you could become either angry or dismissive, and that’s a problem.
“You can’t be angry, that’s the nature of the beast – people are going to come at random times with random crises, and you have to be resilient enough to be able to deal with that.”
Not facing these issues leads to staff burnout, vacancies, and perhaps even a corrosive culture of stigma.
“The minute that there’s a culture that believes that mental illness is a waste of time or a waste of resources, that needs to be resolved.”
5. UPSKILL FRIENDS & FAMILY
Finally, there could be value in upskilling friends and family to understand what a mental health crisis is – much in the same way that first aid is taught for physical health emergencies.
Mental health workers are taught de-escalation techniques for situations that get sticky, and George believes it would be useful for friends and family to know about these techniques as well.
“If people have those skills, they can then use them. If they don’t work, then you know that something acute is really happening.
George relays the story of a girl with an intellectual disability who ended up in crisis because she smashed a glass table, took a shard of glass and threatened to kill her mother.
It turns out that the incident could be traced back to that morning when she’d woken up grumpy and unable to get her DVD player to work, so had pulled out the cords, then been dragged off to a family barbeque she didn’t want to go to.
Upon getting home, she tried to get the DVD player to work again and couldn’t, and by this stage the anger and frustration in her pressure cooker – which had been building all day – burst.
“They were having this altercation on the front lawn, and the glass was gone and all that sort of thing, everybody was safe. But the meddling next door neighbour came across and said ‘if you don’t settle down I’m going to take you to the hospital’.
So she arrives on our doorstep ‘acutely mentally unwell’ according to the family, and I said ‘Well no, she’s not mentally unwell, she’s not schizophrenic, she’s not bipolar, she’s not depressed, she’s just pissed off. All you need to do is plug everything back into the DVD player, put her favourite DVD on and she’ll settle down and she’ll be totally fine’.”
The neighbour continued to push for the girl to be admitted to the ward, and George responded that there was nothing to admit her for.
“After, you know, probably two and a half hours of coaxing and talking and all that sort of stuff, everybody went home and it was all fine.
“But there was this inherent expectation that because the girl was angry she was mentally ill and that it was our job to fix it.”
* * * * *
Crisis teams are there to ‘fix it’, and the cases that come through their doors are not always easy, the resources aren’t always there, and sometimes even the basic human desire to help others is missing too.
Perhaps it’s time to assess our services in the same way they assess the people who come through their doors? For all our sakes, we need the outcome to be good.