In search of ‘normality’

Those planning and implementing crisis and
out-of-hours mental health services need to ensure that service
users’ views are sought and acted upon, writes researcher Heather
Hurford.

Crisis resolution teams are required to be in
place by 2004.¹ Detailed guidance has been published on
the design, management and operation of these services,²
within a national policy framework that envisages that mental
health care will be planned and delivered around the needs and
wishes of service users.

Demand
for these crisis services is likely to depend on a number of
factors, including their ability to work together and respond to
the experiences and needs of service users. Moreover, they are
being developed at a time when services are evolving at many levels
in response to policy requirements and where there are risks
attached to planning any one element at the expense of a whole
picture of local provision. Therefore, it is important for mental
health services commissioners and providers who are still grappling
with the role of crisis services to ensure that their planning is
informed by the views of service users.

Dacorum Primary Care Trust in
Hertfordshire, together with local partner agencies, consulted
service users prior to developing crisis and out-of-hours services
(see below). The focus of the consultation was on services for
people aged 18 to 65, and it was planned and funded under the local
health improvement programme. The findings offer helpful insights
on service users’ perceptions of crisis and suggest areas where
research on a larger scale is needed to provide more rigorous
evidence. Nevertheless, although people’s experience of crisis was
very varied, a number of key themes emerged.

Service users defined a crisis as
an inability to cope with normal life. Being unable to sleep and
the consequences of lack of sleep were perceived as significant
contributors to the development of crises for over half the sample.
Loneliness was also important, as were being very high or very low
with disturbed thoughts, and feeling unable to cope with practical
domestic tasks. Crises were particularly likely to occur when
people experienced more than one of these factors.

We
then asked where users had sought help in a crisis, and it seems
that this happens in stages. Often people are reliant on the
response of the first person they contact for the subsequent
support offered or pattern of events. Nearly half the sample relied
on family or friends as the first line of support when they start
to feel unable to cope with their normal lives. One-third had
contacted their key worker in the first instance. Others had used
existing out of hours services, the Samaritans, accident and
emergency departments or their GP. For 15 out of the 24, this
initial contact had led directly or indirectly to hospital
admission.

What
would help to prevent crisis? Service users said that being able to
contact other people at any time of the day or night was the most
important point. Also, support or self-help groups, talking
therapies, a telephone helpline, and befriending were variously
identified as most useful. In addition, support with practical,
domestic tasks was a strong theme, and they felt that having an
occupation or carrying out purposeful activities were very
beneficial, as much for the opportunity for social contact as for
the occupation itself.

Not
surprisingly, for those with young children, support with child
care was a critical issue. Meanwhile, being listened to and taken
seriously by service staff was considered to be important: this
issue underpinned many of the responses and was emphasised strongly
by a few people who had had very difficult experiences with
professionals.

More
broadly, the elements contributing to crisis, and the extent to
which they may or may not feel manageable or preventable, appeared
to be inextricably bound up both with the complexities of
sustaining the everyday business of life and with the prevailing
organisation of mental health service provision.

Therefore, crises seem to be just
as much a consequence of social exclusion, which is a feature of
many clients’ lives, as the mental health problem itself.
Obviously, while some aspects of crises are inevitable features of
particular illnesses that require high level intervention from
specialist mental health services, others could be addressed
through improved social and vocational opportunities for people
with mental health problems. If social support at this level is
available, in many cases the escalation to problems that require
more intensive professional intervention may be prevented or
reduced.

When
it came to the intervention of specialist services, many of the
service users wanted a broader range of provision, particularly
talking therapies, alternatives to hospital and improved hours of
access. People also talked about a need for information,
continuity, and, above all, consultation.

It
should be noted that these findings are similar to those resulting
from recent nationally conducted service user consultations on
broader mental health service provision,³ and the
implications for service development are becoming clear.

For
example, services whose main purpose is to provide general,
non-specialist support with daily living skills, practical tasks or
emotional support to promote or maintain a person’s ability to live
independently in their own home are gaining prominence in the
national policy agenda, particularly through the Supporting People
initiative. A recent review of the effectiveness of these low
intensity support services found that user-centred outcomes from
this type of service are consistently positive. Users consistently
valued the support of a support worker or volunteer, often in
preference to other more formal service
interventions.⁴

However, policy guidance and
local implementation of the National Service Framework continue to
focus more on high intensity services – crisis intervention teams,
assertive outreach, and home treatment. Yet the consequences of
focusing service interventions on acute crisis responses at the
expense of preventive work are that service users remain
disempowered and services overstretched. So unless high intensity
interventions are built alongside the kind of lower intensity
social and community support identified in this study, these highly
expensive services will remain reactive, and make unattainable the
vision of a mental health system that supports people in settings
of their own choosing.

Consequently, planning for the
development of crisis and out of hours services should be extended
“downwards” to include a capacity to prevent crises. There are a
number of possibilities, including befriending services, 24-hour
telephone helplines, the employment of suitably life skilled people
at a care assistant level in existing services and social
prescription schemes.

Housing providers and locally
based voluntary sector organisations are particularly critical, yet
in many areas these agencies remain marginal to local NSF
implementation processes. They should be seen not just as partners
in consultation but as integral elements of a local mental health
service infrastructure, providing complementary skills, knowledge
and opportunities for funding to those that exist in health and
social services. If the needs and aspirations of service users are
genuinely central to mental health service development, a broader,
more socially inclusive approach is imperative.

The research

Current users of services of the local
community mental health team, of an inpatient ward and of mental
health charity Mind were invited to participate. Twenty-four
service users agreed to take part – all of whom had severe and
enduring mental health problems. The research was conducted by an
independent researcher and took a qualitative approach, using
semi-structured face to face interviews. Interviews were
simultaneously recorded in writing and the findings analysed
thematically. A separate group of users assisted in the design and
piloting of the interview schedule and offered comments on the
findings and analysis.

Heather Hurford is an independent
mental health service researcher and consultant.

References

¹ Department of
Health, National Service Framework for Mental Health, DoH,
1998

² Department of
Health, The Mental Health Policy Implementation Guide,
DoH, 2001

³ The Mental Health
Foundation, Being There in a Crisis, MHF,
2002

⁴ A Murray, G
Shepherd, S Onyett and M Muijen, More than a Friend: The Role
of Support Workers in Community Mental Health Services,
Sainsbury Centre for Mental Health, 1997