Crisis services

Mental health crises and crisis services

listen to ‘Mindcast: crisis services’ on Audioboo

Read a transcript of the Mindcast.

Acute mental health crisis

This booklet and the services it describes are mostly aimed towards the type of mental health crisis where you need urgent help. You may have already been diagnosed as having a severe mental health problem (e.g. schizophrenia, bipolar disorder or severe depressive disorder) or you may be having a first episode of a diagnosable mental health problem.

Mental health crises include:

• suicidal behaviour or intention
• panic attacks/extreme anxiety
• psychotic episodes (loss of sense of reality, hallucinations, hearing voices)
• other behaviour that seems out of control or irrational and that is likely to endanger yourself or others.

These types of situation can also be described as ‘acute’ and require access to ‘acute’ services. Many of the crisis services provided by the NHS and your local social services are designed to respond to these types of acute situations or illnesses.

Other kinds of mental health crisis

Many people may experience one or more episodes of mental distress in their lifetime that they would identify as a crisis, but which does not require crisis or acute mental health services. If you are experiencing emotions or behaviours that are painful or hard to manage (e.g. depression, intense loss or bereavement, or self-harm) you might see this as a crisis. You may still need to access services that you don’t need at any other time, to help you resolve the crisis or to support you until it has passed. This booklet also provides some information about services of this type (see 'Other types of crisis').

Crisis as a turning point

A mental health crisis may be a sign that your care or treatment isn’t working and needs to be changed. It can have serious consequences if not managed well.

But crises can have good outcomes if handled well. They can be a transition point; an opportunity to reassess your life, reach acceptance of your past, and maybe take a new direction. Good and sensitive crisis services can help with this. If handled well, a crisis can also provide valuable lessons as to how similar episodes can be prevented or resolved in future.

What are crisis services?

A crisis service is any service that is available at short notice to help you resolve a mental health crisis, or to support you while it is happening. These services can range from telephone helplines to Crisis Resolution and Home Treatment (CRHT) teams and acute inpatient wards.

Crisis services can be provided by the public sector (NHS or social services) or the voluntary sector (charities or not-for-profit organisations).

Planning for a crisis

How can I plan for a crisis?

If you are experiencing a mental health crisis you should be able to participate as fully as you want in decisions about your treatment and care. All services should take your needs and choices into account at every stage but should also keep you and others safe. The only time you can be treated against your expressed wishes is if you are sectioned under certain parts of the Mental Health Act (see Rights: consent to treatment).

Because you may not be able to communicate choices about your treatment and care during a crisis, you may wish to plan this in advance and let people know what you want to happen. There is now wide acceptance of the principle of advance planning for a mental health crisis and a number of ways of doing it.

Advance statements and advance decisions

An advance statement includes any statement that you make before a crisis, setting out what you would like to happen, for example if you become unable (‘lose capacity’) to make decisions about your treatment. Whether health services have to follow these depends on what the law says about different types of statements.

An advance decision (also known as an ‘advance directive’ or ‘living will’) is a is a legally binding type of advance statement setting out your decisions about future treatments and making clear the things that you don’t want to have. It’s a good idea (but not always necessary) to do this in a written document, with the support of an advocate or social worker. If you lose capacity to consent to (or refuse) treatment, your decisions should still be followed by doctors and other health professionals. The Mental Health Act 1983 gives psychiatrists power to override your decisions, if you are detained and they believe that treatment is needed. It’s different if the treatment is electro-convulsive therapy (ECT), when a decision to refuse it can only be overridden in an emergency. If you know you would refuse ECT in a crisis, you may want to say this in an advance decision.

Other types of advance statement are not legally binding but do set out your views and preferences on a range of things, like treatment preferences or domestic arrangements. Again, if you lose capacity to make those decisions for yourself, and someone else needs to decide things in your best interests, your advance statement should be taken into account.

For more information about advance decisions and statements see Mental Capacity Act 2005.

Joint crisis plans (JCP)

A joint crisis plan (JCP) is a type of advance statement that is agreed between you and your psychiatrist or other mental health professionals involved in your treatment. The aim is to empower you, to plan in case you lose your capacity to make decisions about your treatment and to help spot signs of a crisis.

You could use a JCP to record: information on early warning signs of crisis; advance treatment statements; contact details of primary and secondary care staff for routine and emergency care; details of medication; psychiatric and physical diagnoses; and allergies. Copies are sent to those people that you ask them to be sent to.

Someone helps you draw up the plan and you have the final say. JCPs represent plans that mental health services are expected to carry out as far as possible. A JCP can reduce your chances of being sectioned.

Crisis cards

A crisis card is designed to be carried in your wallet or pocket. It names someone to be contacted in a crisis; information about the care you would like in a crisis; and any other information you feel would be useful.

Care programme approach (CPA)

If you have severe mental health problems, or a range of different needs, your care may be co-ordinated under the Care Programme Approach (CPA).

Every care plan under the CPA should include a crisis plan which gives clear details of who is responsible for addressing elements of your care and support, and who to contact. You should be given a copy of your plan, as should people involved in your care, if you agree.

The plan should cover what action needs to be taken if your mental health gets worse, the services that have worked well in the past, and the name of an individual who you respond well to in times of crisis. It will also give other options in case your first choice of treatment is not available. If the contents of your CPA are followed by people involved in your care, this should ensure that any crisis is handled in a way that is both acceptable to you and most likely to be effective.

Points of contact

Who can I contact?

Some services that provide a first point of contact can both give you immediate support and put you in contact with other services. Mind’s Listening to experience report found that having someone to talk to was a fundamental need for people in crisis.

Telephone helplines

Telephone helplines can provide essential support to someone in a mental health crisis, particularly if they provide 24-hour cover.

Helplines help you make sense of your situation and work out possible solutions by allowing you to talk through your emotions and giving confidential and non-judgemental support. If you are at risk of suicide or in despair, some helplines offer follow-up calls. If you just want information, the helpline operator will either provide it directly or direct you somewhere else that can help. (The Mind infoline provides information on a range of topics, including types of mental health problems and where to get help.)

The best known helpline for people in an emotional or mental health crisis is Samaritans.

Several national charities for specific mental health problems operate telephone helplines out of office hours; for example, No Panic (for panic and anxiety-related problems) and b-eat (the Eating Disorders Association) (see Useful contacts for details).

Helplines also link with NHS Direct, which can refer callers with mental health problems to a local helpline of an approved standard.

Crisis Resolution and Home Treatment (CHRT) teams and Community Mental Health teams may also provide telephone support for people they work with who are at risk of a mental health crisis. You may be able to manage and resolve your crisis by talking to a worker, either through a single call or over a period of days or weeks. If you need more support or treatment, you should be referred immediately.

Most organisations that provide helplines also provide support through other media such as email and textphone. This could be important if you find it difficult (or are unable) to talk on the phone.

The role of GPs

For many people, their GP is their first point of contact with medical or support services at the onset of a crisis and can be a valuable source of support.

A GP is likely to know you well and may see you often. They can therefore play an important role in recognising a mental health problem at an early stage or spot any worsening of your mental health before it becomes a crisis. They can also help you put into practice self-management techniques that have worked for you in the past. If your GP is someone you can talk to, lets you remain as independent as possible, and respects your personal coping strategies, you might find that very helpful in a crisis.

If you and your GP decide that other services are needed, your GP can provide information and advice and make referrals.

Emergency departments

Your first point of contact in a crisis might be the emergency department (Accident and Emergency) of a hospital, especially if you need medical attention for a physical injury.

An emergency department may be a busy and hectic place to be if you are in crisis and not all staff have the same level of awareness of mental health problems. It is best to have a trusted friend or family member with you for support if possible.

For the most part, I've found A&E departments really helpful and professional. They knew how to speak to me calmly so that I could calm down and they treated me with dignity, which is something you sometimes feel you lose when you're in a crisis.

Some emergency departments (two out of five) have a psychiatric liaison team in place to assess your mental health needs, provide short-term treatment and support, and link you into longer-term care if you need it. In some hospitals this is available 24 hours a day. If there is no psychiatric liaison team, a local mental health service such as the CRHT team should be on call to provide help, though they may take longer to arrive.

An assessment will decide whether you are able to remain in the community, perhaps supported by the local CRHT team, or need immediate hospital admission, including being admitted for a short period for further assessment.

Crisis services

Can a crisis be resolved in the community?

Most health services try to resolve a mental health crisis in the community if possible, but it can depend on the services available to support you.

Crisis Resolution and Home Treatment (CRHT) teams

I think it’s great that the crisis teams go out and meet people in their own homes. This is a preventative measure to keep people out of hospital and I think it works – it worked for me.

A CRHT team usually includes a psychiatrist, mental health nurses, social workers and support workers. You might be referred to a CRHT after visiting an emergency department, as described above, or via another service.

The main aim of CRHT teams is to provide people with the most suitable, helpful and least restrictive treatment possible, in order to prevent or shorten hospital stays. A key part of the CRHT team’s role is to decide who gets admitted to hospital or whether they can provide an alternative. They can also offer home support to enable you to leave hospital more quickly.

If you don’t go into hospital the CRHT team assesses your needs, manages the risks of you being at home, assists with self-help strategies, visits frequently, offers psychological and practical help, and administers medication. They should be available 24 hours a day, seven days a week.

CRHT teams also work with family, friends and carers. They have a good knowledge of local services and can help you learn from your experience in terms of crisis prevention and management.

Research has shown much higher satisfaction rates for CRHTs than for hospital inpatient wards. People experiencing a crisis (and their families) generally appreciate knowing that support is available 24 hours a day and this can make people feel safer.

If you live in a rural area, you may find that the service provided by a CRHT is more patchy, because of the distances involved.

Community Mental Health Teams

Community Mental Health Teams (CMHTs) are teams of mental health professionals who support people with ongoing mental health problems living in the community. They often work during office hours and are therefore not set up to deal with mental health crises, which can happen at any time and need a rapid response. However, some people are able to manage a crisis while living in the community, with support from their CMHT along with additional support from people such as their GP, family members and carers.

Some CMHTs provide support outside traditional office hours and can increase visits during times of crisis. If you are at risk of a crisis you should have a named contact and/or a helpline number to call at any time of the day in case you need help outside the CMHT’s hours.

What other community services are there?

Some of the community-based services that you might need to deal with a crisis while living in the community are crisis houses, day centres and acute day hospitals.

Some of these services are provided by the voluntary sector and others by partnership between social or health services and voluntary sector groups. Some of the best draw on the experiences of people who have had acute mental health crises, and some are run by people with such experience. Research has shown greater user satisfaction with these types of services than inpatient hospital care.

You might be referred to these services by a GP, a CRHT team or a CMHT. Or you can get information about them from local NHS trusts, NHS Direct and Mind infoline and in some cases can refer yourself. The main types of community-based crisis services are described on the next page.

Crisis houses

One of the world’s great mysteries is why we don’t have more [crisis houses].

Crisis houses offer intensive short-term support so that you can manage and resolve your crisis in a residential (rather than hospital) setting. Crisis houses are generally liked by people who use them.

There is no single model for a crisis house and in some cases the service might be described as a safe haven or sanctuary. Overnight accommodation is provided, usually through a small number of beds. Crisis houses may be run by people with experience of mental health crisis or have various mixes of mental health support and medical staff.

The criteria for admission and length of stay, and terms and conditions of residence, vary between crisis houses. Some provide accommodation for a group with specific needs, such as women, people from a black or minority ethnic group or people facing a particular kind of mental health crisis. Other criteria include willingness to abide by house rules regarding behaviour to other residents. If you are taking medication, you are usually expected to do so without staff supervision.

You could be referred to crisis houses by a CMHT or CRHT team. Some crisis houses – particularly those set up by the voluntary sector – allow you to self-refer, but you will be assessed before admission to ensure that your fit the criteria for the house. (See Housing and mental health).

Non-residential and day services

Not everyone needs residential services. You may be able to manage a crisis if the right support is provided during the day. Some services provide support late into the evening.

The term ‘day services’ covers a range of activities and settings, from drop-in centres provided by local voluntary organisations (such as local Minds) to acute day hospital services. Not all of these services are set up to help people manage a crisis, but some can do this, if used with other support. Some crisis houses also have a ‘guesting’ service for users who visit during the day but do not stay overnight.

You may find that voluntary services are less concerned about whether you have a specific mental health diagnosis.

Day services can help you resolve a crisis and learn self-management techniques that may help in the future. They can include counselling, other therapies such as art therapy, and activities such as gardening. They may also provide opportunities to talk to others or to have peace and quiet. The staff tend to have a good knowledge of local services and close links with the local CMHT. You can use day services in combination with care provided by an unpaid carer (e.g. a family member) and contact with your GP or a CMHT or CRHT.

When might I need to go into hospital?

The aim of acute inpatient wards is to keep you safe and to assess and treat your mental health problems. Many people report bad experiences of inpatient care, but services are better in some areas than others and in the short term it may be the best option to prevent you harming yourself or prevent the symptoms of a crisis from getting worse.

…In psychiatric units, the most successful ones are those that organise activities for the patients, get them involved in their care, and take time out to actually listen to them, to their needs, and even just be someone to listen to them when they’re feeling down…

Some people feel safer and more secure in hospital than at home, perhaps because they feel that their mental state has been recognised, they are protected from the risks they pose to themselves or others, and they get a break from the difficulties they experience at home. While some people find the routine of hospital oppressive, others find it a useful way to provide structure to their day, motivation to get out of bed and a group of people to socialise with.

Research by Mind has found that many people in crisis have difficulty accessing inpatient accommodation. If you do want to go into hospital, whether you are admitted may well depend on whether there are beds available, as well as the social support and services available to you at home.

If you are admitted to hospital because of a mental health crisis you should be consulted about your care plan, which outlines your care and treatment. The plan should name one person who will act as your care coordinator. This person should also be involved in creating a care plan when you leave hospital, which should include ways of preventing and resolving any future crises (see Care programme approach).

Wards should offer appropriate care, treatment and activities. They should also be safe and secure with the minimum restriction necessary. On most acute inpatient wards there will be a mixture of voluntary patients and others who are compulsorily sectioned. The law says that health services have the same duty to keep voluntary patients safe as applies to sectioned patients. This may affect how much freedom you have. Many more wards are now locked, which means that as a voluntary patient you could feel more restricted than you would like.

Nearly all hospitals now have single-sex sleeping accommodation, in line with government policy, but some still have mixed facilities during the day, which may make some people feel less safe.

In 2011 the Royal College of Psychiatrists published a booklet Do the right thing: how to judge a good ward. This featured a checklist of 10 standards, covering issues of ward size and occupancy rates; a safe and therapeutic environment; access to therapy; involving and respecting patients and cultural sensitivity.

Other types of crisis

Services for other types of mental health crisis

Anyone can experience an episode of mental distress in which emotions or behaviour become painful, out of control or difficult to manage, even if they do not have a severe mental health problem.

In such instances, you may feel a need for more help than can be offered by family or friends, and seek help that you would not need at any other time. You would not usually be referred to the type of crisis services already described in this booklet. This section describes other types of help you might need.

The role of GPs

Your GP is well placed to help you if you are experiencing a crisis that does not require acute or crisis services.

Through your GP, you may be offered access to a counsellor or therapist, either directly through the GP practice, or through being referred on to an Improving Access to Psychological Therapies (IAPT) service. The treatment you are offered is most likely to be cognitive behaviour therapy (CBT).

GPs may also prescribe medication, such as antidepressants. Antidepressants are not the answer for everyone and do not address the underlying cause of a crisis, but they may be helpful for symptoms in the short term.

GPs can also give advice on lifestyle factors that may be affecting your mental health, such as diet and exercise, or refer you to a specialist or for assessment by secondary mental health services, such as a CMHT.

Telephone helplines

Telephone helplines can be a good resource for immediate support. The Samaritans’ helpline is available to anyone in distress or despair, as are the helplines of national charities that focus on specific mental health problems.

Online support

The internet can be a good source of support if you are experiencing a crisis. Online facilities provided by NHS Direct, Mind and other leading national charities in mental health provide high-quality and up-to-date information and support services. In addition, they often provide links to other relevant websites, including those created and maintained by people with mental health problems.

Many people in a crisis also find it helpful to make contact with others who have had a similar experience. Online discussion forums could help you overcome isolation, gain moral support and learn practical tips for coping with and resolving your crisis.

Note, online resources are not necessarily subject to the same quality control as telephone helplines. Moderation is the assessment of comments, before they go ‘live’, to prevent information that is offensive, false or likely to cause harm from being publicly available. Discussion forums that are not adequately moderated may also be best avoided.

Some websites do not promote recovery or healthy ways of managing a mental health problem, but are aimed at triggering negative behaviours, thoughts and feelings. They are likely to be unhelpful and possibly dangerous if you are in a crisis.

Voluntary organisations

Local voluntary organisations involved in mental health, such as local Minds, may be able to help you through a crisis by providing information, advice, counselling and/or other day services. Information about what is available locally can be obtained from your GP, CMHT or local NHS trust, or by contacting Mind’s infoline.

Useful contacts

 Mind Infoline
tel: 0300 123 3393 (Monday to Friday, 9.00am to 6.00pm)
email: info@mind.org.uk
web: www.mind.org.uk
Details of local Minds and other local services, and Mind's Legal Advice Line.  Language Line is available for talking in a language other than English

beat (beat eating disorders)
adult helpline: 0845 634 1414
email: help@b-eat.co.uk
youth helpline: 0845 634 7650
email: fyp@b-eat.co.uk
text service: 07786 20 18 20
web: b-eat.co.uk
Charity with a network of self-help groups and individual postal, telephone and email contacts

Hafal
tel: 01792 816 600
email: hafal@hafal.org
web: hafal.org
The leading organisation in Wales working with individuals recovering from severe mental health problems and their families

Bipolar UK
web: bipolaruk.org.uk
tel: 020 7931 6480
Support for people with bipolar disorder (including hypomania) and their families and friends

NHS Direct
tel:0845 46 47
web: nhsdirect.nhs.uk
A 24-hour information and advice on any health problem or service. The website has a Mental health section providing advice about what to do if you or someone close to you has a mental health problem

NHS Choices
web: www.nhs.uk
Comprehensive information about NHS services and medical advice

No Panic
helpline: 0800 138 8889
web: nopanic.org.uk
A voluntary charity which helps people who suffer from Panic Attacks, Phobias, Obsessive Compulsive Disorders and other related anxiety disorders including those people who are trying to give up Tranquillisers

Samaritans
24-hour helpline: 08457 90 90 90 
email: jo@samaritans.org 
web: samaritans.org
Freepost RSRB-KKBY-CYJK, Chris
PO Box 90 90
Stirling
FK8 2SA
Emotional support for anyone feeling down, experiencing distress or struggling to cope

Published 2012
To be revised 2014
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