Effectiveness of Crisis Resolution on Patients

                Crisis is defined here as a failure in adequate coping associated with an acute episode of mental illness or distress. It is a brief, non-illness response to stress and is not considered as a clinical disorder although it can cause one. At the same time, stress is not a crisis, although it may again cause one.

                Crisis intervention or resolution is defined as a rapid response and intense, short time work, in the “here and now”. It is aimed at diagnosing maladaptive responses, such as denial of difficulty, failure to express feeling, avoidance of help, and in providing help so that healthy coping can be achieved (Social Systems Intervention Part I).

                Crisis Resolution Team has been proven to be successful in keeping some individuals with severe mental health crisis out of the hospital. Moreover since its first introduction in England, it is successful in reducing voluntary admissions to hospitals and the new service has been proven to be more satisfactory to the patients.

                In 2005 Johnson and colleagues conducted a randomized control trial to evaluate the effectiveness of a crisis resolution team. Participants of the study included 260 residents of the inner London Borough of Islington who experienced crises severe enough for hospital admission. Acute care including a 24 hour crisis resolution team (experimental group) was compared with standard care from inpatient services and community mental health teams (control group). The result of the study showed that patients in the experimental group were less likely to be admitted to hospital in the eight weeks after the crisis. However compulsory admission was not significantly reduced. It was then concluded that crisis resolution teams can reduce hospital admissions in mental health crises. Additional finding suggested that it may also increase satisfaction in patients although this finding was equivocal (Randomized controlled trial 2005).

                After the North Islington study conducted by Johnson and colleagues several issues have been raised. Initially it is noteworthy that patients’ quality of life improved and that admission rate decreased since the advent of the Crisis Resolution Team. The study reported that patients’ satisfaction is unequivocal. Some possible reasons for this are: Perceived Refusal of Admission, Inability to see Doctor Always and Assessed by Different "faces" during their Presentation.

                As to the lesser number of hospital admissions, some critics pointed out that the study should have included a cost efficient analysis. Although it seems beneficial that hospital admissions are lessened, an actual cost efficient study would have provided an actual summation of the cost of the Team against that of hospital expense.

                Since the implementation of the Crisis Management Team, several trainee psychiatrists have also voiced out their complaints regarding the “deskilling” of their assessment skills. Before, trainee psychiatrists are given a chance to actually assessing the patients in their own in the A&E. This is an essential part of the training experience of these psychiatrists. With the advent of the Crisis Management Team the trainees no longer gained such learning experience. Although such “deskilling” could be overcome by a posting with the crisis team some trainees found it not similar with the learning experience they had prior to the implementation of the Crisis Management Team (Crisis Teams: Why 2005)

                Another feedback from the Islington study questioned the vagueness of the outcome and the usefulness of the study. According to Fenella Lemonsky patients with personality disorder who have high rates of crises were not identified in the study (Crisis Team 2005). Compared with other boroughs Islington has a very well resourced comprehensive mental health service, including the Tavistock clinic which can contain the patient better even on a long term basis. Further, Islington also has access to junior or senior psychiatrist. Other boroughs do not even have specialist personality disorder service for the patients with complex needs the time the study was conducted.

                Another important aspect of the study is the lack of reduction in involuntary admissions. It has been observed that most of the patients who were screened and managed by the crises teams eventually require inpatient admissions. Some suggested that the crises management team only delayed the admission or an inpatient management. The equivocal patient satisfaction highlighted in the study only suggested that the delay may not be for the best interest of the patient. One can say that the aim of the crisis management in reducing admission is not at all necessary.  In fact, it only stressed that what is important is to meet the needs of the patient including inpatient admission (Lack of Reduction 2005).

                In terms of how staff groups feel toward the Crises Teams, it was reported that the general view amongst staff was that Crisis Team involvement was more often than not unhelpful. Some even reported that they see it as an occasional harm to patient care. Citing one 2005 report, in the Trust-wide policy that Crisis Teams have to be contacted prior to arranging a Mental Health Act Assessment, some patients are extremely sick, requiring confinement to the hospital, but will not accept home treatment (Dissatisfaction 2005). Now because of the Trust-wide policy, before being admitted to the hospital, the crisis team and the patient must discuss whether the patient will accept home treatment. Some staff of the team considers this as a total waste of everybody’s time and resources. Most of the time patients would not accept any form of treatment, hospital or home treatment. In some cases discussing it with the patient often resulted in the patient running away from home to avoid being hospitalized. In these cases the patient harms himself, and sometimes even others. Another problem that was not given a thorough examination by the study is the exclusivity. There are many cases wherein patients become ineligible for crisis teams because of their use of drugs and alcohol. These patients require help but the crisis teams are helpless. These are also the patients who may cause harm to self and others. More often it is not advisable to wait for the CRT to arrive, evaluate and administer home care.

                Comparing that with the Crisis Intervention Team (CIT) found in the Memphis Police Department, in the Memphis CIT the uniformed officers are specially trained in mental health issues and act as primary or secondary responders to every call on mental illness cases (Contact with Law Enforcement 2007). By designating the police, CIT officers are available 24 hours a day and can directly bring the patient to the hospital to ensure that no danger will arise from the attack. Several police departments have adopted the CIT approach across the United States and have found it quite effective in dealing with mental health cases.

                With the varying responses and reactions to the study, Johnson and colleagues made several replies to most of them. In the limited differences in satisfaction, they agreed that the differences require further study. They added that the study should also include more details on patients’ view about Crisis Resolution Teams.

                On the inclusion and exclusion criteria, the authors stated that “neither personality disorder nor substance misuse were exclusion criteria as substantial numbers of participants had these problems”. This is somewhat confusing as the report stated above was from a staff of the CRT. Perhaps there is a problem with the implementation of the policy, in which case it is the patient who suffers from the lack of required treatment and the staff from feeling demoralized.

                On admission as an outcome measure, the authors argued that admission is a controversial outcome measure even from the very beginning. The authors stated that people will always find ways to criticize the objective of lessening the number of hospital admission. Some people can always state that hospitalization is still the best way to meet the patients’ needs. The authors agreed that this is true but pointed out that recent literature suggested CRT is now gaining popularity among the users. That the users now find it very helpful an alternative treatment to hospitalization is now available provided that these treatments are as safe and as effective as that in the hospital.

                On representativeness of the study setting, the authors argued that Islington was not chosen for the study a representative of the United Kingdom as a whole. They agree that further evaluation of other settings should be conducted to gain a full view of the CRT. On the definition of a crisis on the study, it was the patients experiencing a crisis severe enough for hospital admission. This is the same criteria used by the CRT. The crisis houses are residential services based in the community, staffed 24 hours, with means for practical and psychological support. They do not include formal psychotherapy and psychiatrists.

                On blinding, the authors argued that since the staff were involved in the study process, it was not possible to prevent them from knowing that they are doing a trial. The authors acknowledge that although it may have caused some bias it is unlikely that this affected the study on a large scale.

                On the role of CMHT in home treatment, the authors argued that the CMHT in the study were well established, the health and social care staff often carried out home visit, the caseloads were below 25 per worker, available Monday to Friday 9am to 5pm, visited more than once a week and thus could be considered as a representative of a reasonably good established and resourced UK CMHT. However they cannot offer out of hour response to crises and augmented CMHT was not the norm in the UK. The authors remind that this limits their service and that further study on the issue should be undertaken. They further argued that an augmented CMHT definitely is more advantageous in terms of continuity of care but even with an augmented CMHT may not be suitable for all settings, as rural demands are different with that of the metropolitan areas (Authors’ response).

                The study was conducted in 2005 and the reports or responses are on the study. Many developments have been initiated since the conception of Crisis Management Team back then. However, even with the adjustments and developments made since then, the initial problems of Crisis Management Team are still here. This is particularly true on the issue of the perception of the citizens.

                Foremost is the perceived refusal of admission. If the implementation of the Crisis Management Team has been perceived, or still being perceived, as a hindrance in properly seeking professional medical help, perhaps it is. People would not normally want to go to the hospital. They would rather “take a pill”. Now, considering the availability of the Crisis Management Team in a borough, for convenience alone, people would avail of this service and if the care provided solves their health problems, they would not insist on going to the hospital. It seems then that since patients perceive CMT as a refusal of admission, the care provided by the CMT is not enough to meet the demand of the patients.

                Second, this perception may also mean that CMT may actually be a hindrance for admission. Perhaps patients who feel they need to go to the hospital felt deprived of their right to seek help in times when they need it most. This perception may also mean that CMT may actually be a hindrance for admission. Perhaps patients who feel they need to go to the hospital felt deprived of their right to seek help in times when they need it most.

                This is also very much related to the citizens’ sentiment of “inability to see doctor always. People who are sick and their families would want the reassurance of the doctor. Even if the CRT are trained professionals, there is much to be said about the dissatisfaction of the community about this aspect of the CRT service. It may be cost effective for the nation to have lesser number of admission to the hospital but the perceived quality of life of the citizens are being sacrificed.

                The same can be said about the negative effect of the one of the most common complaint, which is of being assessed by different “faces” during presentation. This lack of personalized treatment is very un-reassuring for the patient and the family members who primarily sought medical assistance in order to be reassured.

                In every crisis, the person or persons involved wants nothing more than to feel safe. Under that premise, one cannot feel safe in the hands of the community. The right of the individual to feel safe is therefore being violated. Further, when one is refused being admitted to the hospital, one has to rely on family members or friend for the day-long care required by the patient. It is now very common to hear of friends and families taking time off work just so they can take care of the patient. In some cases family and friends even lose their jobs because of the crisis. This could create a great impact on the finances of the family, not to mention the guilt of the patient and the disheartenment of the family member who got fired from the job.

                Now after the crisis, the patient has to face the whole community with the full knowledge that the community had full knowledge of the crisis. This can be very humiliating and may cause a stigma for the person and his family. Having the crisis in full view of the community leaves one without any privacy, not to mention being subjected to the possible negative perception of the community.

                Further, because of the negative effects of the CRT, this may create a cycle of requiring more therapy and more outpatient appointments. One then has to ask if CRT really helps the individuals with mental health problems. Or has it become a tool that although designed for constructive use, has caused more harm than cure.

Yes it is legal, but the question is: is it ethical? Based on these premises, the CRT violates many basic human rights and as such has also created many legal problems. Foremost of which is the question of liability. Many cases have been reported about the negative effect of CRT on the patient outcome. Sometimes the delay in proper treatment and other examinations required to make a proper diagnosis could be fatal. In these cases the question of liability is a legal matter but few family members could pursue the matter since CRT is mandated by law.

                In the United States, “advance directives” or “living wills” are legal papers executed by the patient stating his preference for a particular medication or treatment alternatives in case of crisis wherein they can no longer express themselves. In cases of individuals with mental health problems, the ability of the Crisis Intervention Team (CIT) in the US to follow such directives sometimes cause long legal issues. People with mental illness still have the right to have their wish followed. With the Crisis Resolution Team, the whole idea of advance directives is totally out of the picture. Not only because the individual is not given any chance to choose the medical treatment he prefers but also because he is confined to whatever resources the CRT can provide.

Bibliography

Bridgett, Christopher, Polak, Paul. 2003. Social systems intervention and crisis resolution.

                Part 1: Assessment Adv Psychiatric Treat 2003, 9: 424-431

Bridgett, Christopher, Polak, Paul. 2003. Social systems intervention and crisis resolution.

                Part 2: Intervention. Adv Psychiatric Treat 2003, 9: 432-438

Contact with Law Enforcement 2007. Consensus Project

                (Online) Available at:

                http://consensusproject.org/the_report/toc/ch-II/ps03-on-scene-assessment

                (Accessed 25 April 2007)

Donegan, Tony. 2005. Dissatisfaction of mental health professionals with the CRT's.

                Published Sept 2005       (Online) Available at:

                http://www.bjm.com

                (Accessed 26 April 2007)

Johnson, Sonia, Nolan, Fiona. 2005. Authors' response. Published Sept 2005

                (Online) Available at:

                http://www.bjm.com

                (Accessed 26 April 2007)

Johnson, Sonia, et. al. 2005.  Randomized controlled trial of acute mental health care by a crisis resolution team: the north Islington crisis study. Published Sept. 2005

                (Online) Available at:

                http://www.bjm.com

                (Accessed 26 April 2007)

Lemonsky, Fenella. 2005. Crisis Teams Published Sept 2005

                (Online) Available at:

                http://www.bjm.com

                (Accessed 26 April 2007)

Subramanian, Dr Arun Prasad, 2005. Crisis Teams: Why are Patients and Trainee Psychiatrist not satisfied! Published Sept 2005 (Online) Available at:

                http://www.bjm.com

                (Accessed 26 April 2007)

Subramaniam, Hari. 2005. Lack of reduction in involuntary admissions Published Sept 2005

                (Online) Available at:

                http://www.bjm.com

                (Accessed 26 April 2007)