Acute alternative

The Mental Health Foundation is asking the
government to help set up more community-based crisis intervention
services as there is wide recognition that acute wards alone cannot
meet the needs of service users. Anabel Unity Sale reports.

Every year thousands of people with severe
mental health problems use acute psychiatric services. In the year
to 31 March 2001, there were more than 100,000 admissions to
hospital for severe mental health problems such as schizophrenia,
psychosis and manic depression.

A report published this week by the Mental
Health Foundation says hospital crisis services are not meeting the
needs of these users. Being There in a Crisis, produced in
conjunction with the Sainsbury Centre for Mental Health, says
current care in the UK is failing to meet demand and struggling
against a backdrop of negative publicity.

The report’s conclusions are stark.
“Psychiatric in-patient services are over-stretched and often able
to admit only the most seriously ill people, and most services
offer little more than medication and containment.”

Alison Faulkner, head of user initiatives at
the Mental Health Foundation, describes hospital-based crisis
services as unsatisfactory. The increased emphasis on community
care services has resulted in acute services being left behind. She
says: “Acute wards have rather lost their focus and role in the
crisis system.”

This is not helped, she says, by the practice
adopted by some hospital wards of sectioning people under the
Mental Health Act 1983. She says: “This makes any potential
patients want to avoid hospital-based crisis services as much as

Faulkner has herself used acute crisis
services. The last time was two years ago and she found the ward’s
environment threatening, and says she witnessed other users being
treated badly by staff. “I was ignored by staff,” she says. “The
quieter you are the less likely you are to get into trouble.”

Terry Simpson is the national co-ordinator of
national advocacy organisation Ukan. He also has first-hand
experience of acute crisis services, having been sectioned twice.
He last used traditional crisis services 15 years ago.

He says the dual roles of in-patient crisis
services conflict. Policing the behaviour of users and looking
after people thought to be a danger to themselves or others do not
go together. “If a person is in a crisis they should be able to
talk freely about what is happening to them,” he says. “Traditional
crisis services can sometimes hinder a person’s rehabilitation
because they don’t do this.”

Staff working in mainstream crisis services do
not have the time to work effectively with users, according to
Richard Brook, chief executive of the mental health charity Mind.
He says: “The physical conditions of many services are also poor
and many users report the environment as untherapeutic.”

Angela Greatley, a fellow in mental health and
social care at the King’s Fund, says this is often the case in
acute psychiatric services in big cities because of the high demand
they face. She says that although acute hospitals offer users
“time-out” from their crisis, the use of medication is commonplace,
and they rarely offer alternative forms of therapy.

Greatley says: “Some people may not like the
side-effects of taking medication or want to try talking therapies
and work through their problems in a systematic way.”

Some users, she adds, do not find acute crisis
services a therapeutic environment because they are not responded
to as individuals. “A big ward environment can be depersonalising
because it runs to a set of rules that are about the institution
and not the individual,” she says.

Being There in a Crisis reviews the
Mental Health Foundation’s crisis programme, which has supported
the development of seven complementary and alternative crisis
services in the past three years. The programmes include crisis
houses – safe places for people to go to in a crisis – as well as
drop-in centres and helplines. The review concludes that these
user-led crisis services have real value and are appreciated by
those using them.

Its main recommendation is for national
investment to help establish community-based crisis services for
people with severe mental health problems. Developing such
services, it argues, will mean that users can access help when and
where they want, without relying on traditional crisis

The report’s authors call on the government to
“act on the evidence that acute wards and crisis teams cannot meet
all needs” and to “ensure that people in crisis have access to a
wide range of services, from user-led crisis houses to telephone

It urges local mental health agencies,
including commissioners and providers, to ensure that referrals
made by individuals and mental health teams are to both types of
crisis service equally.

Faulkner says she can see no reason why
community-based crisis services should not become part of the range
of everyday health services available. “Everyone should have access
to a crisis service outside of a hospital because it can do
different things.”

The report also recommends community-based
crisis services be developed for specific target groups, such as
women and people from ethnic minority backgrounds.

According to Faulkner, developing crisis
services for people from ethnic minority backgrounds would make a
huge difference. “We know that young black men do not come into
contact with crisis services often,” she says. “It is important to
provide help earlier that is more accessible so they do not put off
entry to the service.”

Peter Beresford, chairperson of Shaping Our
Lives, a national organisation for users of social care services,
supports the idea of operating non-medicalised, user-controlled
crisis services. He says: “Community-based crisis services are
important because people want somewhere where the diagnosis process
[of acute services] is not replicated.”

Brook also supports the idea. He says: “It is
very clear from previous evidence that women and people from ethnic
minorities traditionally find it hard to access and use mental
health services.” Such services, he adds, must also take into
account local need and existing provision.

Greatley says user group-specific crisis
houses would give people the opportunity to come to terms with
their crisis in a more protected environment than that of an acute
ward. She adds: “Small crisis houses can be more responsive and
understanding of the mental illness of someone from a particular
cultural group.”

So how do people with severe mental health
problems respond to community-based crisis services?

The research suggests that most users are very
receptive to community-based crisis services and welcome the
alternative to psychiatric wards – not least because it allows them
to remain in their own homes.

In addition, such services can lead to users
feeling more in control of their lives. According to Brook: “For
many users crisis services are less stigmatising and threatening
than hospital in-patient care. They offer support that can be hard
to access in other ways in the community.”

Although the report recommends developing more
community-based crisis services, Faulkner stresses that such
services should work alongside existing acute services. The report
warns: “Residential crisis services must not develop at the expense
of hospital in-patient care.”

Brook agrees. “A community-based crisis
service should be seen as a positive and useful additional
resource,” he says. Close liaison between both types of crisis
services, he says, is essential if the community-based services are
to succeed.

Having a variety of crisis services to choose
from would also be welcomed by doctors, social services, community
nurses, according to Simpson. He adds: “It is a lot easier for
professionals to leave you in your own life if you are already
living it.”

Beresford says there is room for both types of
crisis services. He says: “Making this kind of crisis provision
available is important but it should not be seen as an alternative
to acute wards.”

While there is plenty of room for the
improvement of acute services, community-based crisis services can
also provide the answers for some users. As Faulkner says: “If
people can learn to value themselves while in crisis services then
that is half the battle won.”

Being There in a Crisis is
available from the Mental Health Foundation, on 020 7802 0300

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