Coping in a Crisis
Many people who care for someone with mental illness will experience difficult times. This may take place when that person’s mental illness is poor and needs additional help. Whether this might be for someone who is not yet diagnosed with a mental illness or for someone who has a long history of mental illness, it can be difficult to get help.
Why can it be difficult to get help?
You probably know better than most when someone you care for is getting ill and perhaps when you or they are reaching crisis point.
It is not always easy to get help. There are several reasons for this.
Some professionals will not accept information from you about your relative’s health and ask that the relative come and talk to them themselves. This can often be the case with GPs and is a misunderstanding about the rules on confidentiality.
Sometimes professionals may want to assess the situation themselves. This can often take time and staff are not always immediately available. If a situation is recognised, sometimes there are not the services to deal with the person, for instance, there is often a shortage of psychiatric beds in local hospitals.
Help for carers during a crisis
It is important when trying to get help for someone with a mental health problem in a crisis situation that you also take into consideration your own health. You will not be as effective if you also become ill.
Professional services are one of the first places you should look for help. They are experienced in assessing people with mental health problems and accessing care and treatment, and if the person you care about is already involved with mental health services, they may already know about some of the difficulties you are having.
The following people and services are worth trying:
The GP can refer someone to a psychiatrist or to the local community mental health team as well as prescribing medication or arranging talking treatments. It may be helpful to ask for a home visit if you live with the person you are worried about.
If you are in crisis during the night, most GPs have a 24 hour ‘out of hours’ telephone number. You will usually not be able to talk to a specific GP so they will not know your circumstances. Because of this you will need to give them a good description of the situation making it clear what you want to happen; for instance, if you want them to come out. Some GPs will not help unless the patient directly requests it. This can cause problems if the person involved is convinced that they are not unwell (sometimes called a lack of insight) or does not want professional intervention. Some GPs are very good but often GPs knowledge of mental illness is limited and they are insufficiently aware of the need for prompt action.
Ask to see a community psychiatric nurse (CPN)
Community psychiatric nurses often work with GP practices or mental health centres and some can be seen on request. They should be familiar with all forms of mental illness and know how to access help.
Contact the local community mental health team (CMHT)
This may result in help especially if you or the person you are concerned about is already known to the team. In some areas the local team will only help if the person has been referred by the GP.
Contact the crisis resolution team
The crisis team deal with people both known to the mental health services as well as those that are not. As well as crises they act beforehand to prevent a person needing to go into hospital. However, if they do need admission, they can arrange this. They usually aim to see someone within a few hours of referral. Referral can be made by a GP or psychiatrist, but sometimes by a carer or the person themselves. There is often a crisis line where you can talk directly to a member of the team or psychiatric nurse.
Contact the local psychiatric crisis line
Many mental health trusts have an out of hours crisis line. This is usually for use of patients but can be used by carers in times of crisis. Sometimes this is answered by a member of the crisis resolution team but other times is answered by a psychiatric nurse, often in the local psychiatric hospital who can advise you or access additional services.
Take the person you are concerned about to A&E / Casualty
Sometimes A&E staff will be able to call the duty psychiatrist to see someone who is having mental health difficulties. This might result in admission. Going to an A&E department can involve a long wait in sometimes distressing circumstances.
Contact NHS Direct
Depending on the circumstances, NHS Direct (0845 4647) may be able to call your GP and emphasise that you are dealing with someone with a psychiatric crisis and request a home visit.
The Mental Health Act
The Mental Health Act (section 13, paragraph 4) gives the nearest relative of someone who is mentally ill the right to insist that an approved social worker (ASW) interviews the person to assess whether they need to be admitted to hospital for further assessment or treatment. The nearest relative is determined by a formula set out in the Act, usually the spouse/same sex partner or older parent or oldest brother or sister).
If the ASW and two doctors agree that admission is necessary, then the person can be 'sectioned' and taken to hospital and admitted without their consent. The police will often be called when someone is sectioned. This is to ensure the safety of everyone involved.
Most people would only use this as a last resort. It could have a negative effect on your future relationship with your relative. However, under certain circumstances it may be the best thing to do and ultimately help your relative. If the ASW decides that admission to hospital is not necessary, s/he must state what other forms of support will be made available. This right to assessment can be used several times if necessary.
Problems getting help
Persistence is important in getting help. Try each of the suggestions for help, and in many instances you may need to try them several times. If you are still denied help or the help you receive is inadequate you can threaten to make a formal complaint.
All doctors, hospitals and mental health services have a complaints procedure.
If you require help in making a complaint, contact your local mental health advocate. If there is no response to a request for an assessment from a nearest relative, it may be possible to threaten 'judicial review'. This would be taking the provider of the service (the assessment) to court to determine whether they have carried out their duties to assess your relative.
If you are offered help but you find that the help is insufficient and you are still experiencing a crisis situation due to someone’s mental health problems, it is important that you ask for help again. Take the time to note down why the help that has been offered is insufficient and what you want to happen. Occasionally you may be given unhelpful advice from a professional who might refuse to help arguing that the problems are behavioural or that no help is available until there is more of a crisis.
Tips for Dealing with Difficult Behavior
This page provides a list of useful tips to bear in mind when you are dealing with difficult behaviour in someone you care for. 'Defusion' means verbal and non-verbal ways of reducing tension between you and this person. These tips were developed from practice. The more you try these tips, the better you will become.
- Don’t invade their space. People like to have their own bit of territory, such as their own chair. Stay an arm’s length away. Avoid corners yourself and cornering the person. Always knock on their door.
- Get to know the signs of rising tension. These could be rocking, stuttering, colouring of the face, pacing, hand-wringing.
- Keep neutral body postures. Keep your hands in sight, no clenched fists, no hands on hips, no pointing, no leaning over people, make eye contact but don’t stare. You are trying to make your own non-verbal communication non-threatening. They say that 90% of communication is non-verbal. Smile!
- Let everybody win. If you can defuse a situation you have won. If your loved one has not lost face, has kept their pride, they have won too.
- Establish a warm environment. This can mean a lot of things, from literally turning a heater on, to sitting by it to talk things out, to being sensitive about colour schemes or the effect of uniforms/the clothes you wear.
- Self-awareness. If you are in a grotty mood don’t pretend you are feeling great or that it doesn’t matter. Just being aware of your mood can help you make adjustments to how you deal with any given situation.
- “Walk, don’t run”. Apply this in loads of ways, for example, lower your voice, move slowly, avoid sudden movements.
- Count to ten. This really does work. When first faced with a situation, start counting to ten. As you do this, check your mood, assess the situation, decide on a first course of action, confirm it to yourself, then do it. You will be more likely to gain control because unwell people are very often frightened people and do not know what is going to happen next. Your loved one will develop confidence in you to come up with safe solutions.
- Use humour. A good one-liner can be worth all the other tips put together. One son joked, “I know the voices aren’t really me. They’re much too clever.” Avoid negative humour like sarcasm, put downs, jumping to conclusions.
- Empathise. This means “I know how you feel”. You can’t always but if you think you do, then use it.
- Sympathise. This means “I agree with you”. Someone may well be right to show anger or distress. Develop this by talking about ways of doing something about it.
- Once you get someone talking, let them let off steam, don’t try to stop them. Ask open-ended questions like “How did that make you feel?”, rather than closed-ended ones like “Did you do that?”
- Use phrases along the lines of, “Lots of people feel that way when they are ill” or “You are not alone in thinking like that” or “That’s not you, that’s the illness”.
- Split up the people involved in an argument. This sounds obvious but take one off for a chat. If this is not possible, get them both talking to you, not so much at each other.
- Sit out a threat. Never ever accept any kind of invitation to join in an argument or fight. This will be appreciated because you become safe. By setting a limit, you reassure. Threatened violence to a named individual is always to be taken seriously. Ask for any weapons or implements to be put down, not handed over.
- Women are as good at defusing as men. There are more differences in individual ability within the sexes than there are between them. If your partner is dealing with the situation, you could just let yourself be seen. Be around to be called upon.
- Accept that your life has changed, at least for as long as your carer or loved one is ill. If a problem develops, be prepared to stop everything, ignore a deadline or be late for something. It also means take breaks yourself, even when that also inconveniences someone. You all need respite breaks.
- Physical contact. Don’t wake someone abruptly or aggressively as this carries a high risk of an equal response. Don’t touch the back of the neck or take a grip on the arm.
- Some homes have places where tensions seem to come out. Think of some practical improvements like muting the colour scheme. Make some quiet space where you can go for a chat or just to get away or play relaxing music.
- Develop your own ways of defusing. Ones that suit your family, your personality, the one who is ill. Apply the solution that fits. If that means getting a respite break because you are not getting enough sleep, apply for a carers’ assessment and ask for what you believe you need.
- Know how to call for help in an emergency. And have the means to it handy, such as the number of the local crisis response team written down next to the phone or in the phone memory.
- All of these are for the immediate situation. At the end of the day, don’t accept the unacceptable. Zero tolerance of violence or aggression has to be the rule, so talk with your care team about how to deal with it.
- If you have managed to defuse a tense situation, wait till a good time and then decide what to do about it. You could have a family conference to devise a plan you can all stick to. For some carers dealing with difficult behaviour is a fact of everyday life. You still need to plan for how you are going to cope in the long run. There will be times when you want to give up caring. Better to plan for your role and get a Carers’ Assessment of your own needs.
What to do if you think someone you care for is at risk of being hurt by someone else
If you are concerned that an adult you know might be at risk of being hurt by somebody else, please contact the Safeguarding Adults At Risk Team on 020 8 891 7971. You can find out more information about the procedures which surround protecting adults at risk on the council's website.