Part two of two: Closing the loop, the continuation piece of a patient’s journey with a mental health crisis in an English Emergency Department. Part one provides additional background and the start of patient’s journey.
After a decade of emergency room nursing in the USA, the compare-and-contrast of working as a nurse in England this past year is constantly eye-opening. I’m thankful to those I work with for the learning experience. For example, there is Amy, a RMN (Registered Mental Health Nurse) who has helped me understand the mental health system in England. Something very different from what I was used to in the States.
Amy
One summer afternoon, Amy shared with me some of her adventures as we walked along the Itchen River. Amy took off traveling soon after finishing her dual degree in mental health and adult nursing. She headed to a remote area of Mozambique to volunteer in a clinic. A place so impoverished that each patient kept a pin cushion with a single needle to use for their injections. Still to this day the thought of it startles her. After Mozambique, she headed to New Zealand. With a soft giggle, she told me how she got lost in the wilderness while hiking. And how her Trust in the universe led her back to safety.
She had taken off a solo, climbing into the New Zealand backwoods, not seeing a soul for days. At one point, she told me, “I was in the middle of the bush and didn’t know which way to go. I was utterly completely lost.” So she just stopped. She stood there. “I asked the universe for help and a bird appeared. I decided it was a sign, I followed it, and it led me out, back to safety.”
Amy is the kind of person who allows the universe to guide her; she is a strong woman with a gentle soul and great source of mental health knowledge. She is one of the people you may see if you come with a mental health crisis to the Emergency Department. Or as it is called in England, the A&E, for Accident & Emergency.
Before seeing the patient
Prior to evaluating the patient in the A&E, Amy logs into a larger data base using the patient’s National Health Service (NHS) number. There she can see their social, medical, and mental health history. She is also able to see which resources have already been established in the community for the patient. And whether the patient has used them. Every person that lives in England should have an NHS number. On a side note, we were able to spot a person being sex trafficked due to their lack of an NHS number when I first arrived.
A Suicidal Patient
Every day we have at least one patient that has intentionally overdosed on their medication or over-the-counter paracetamol (acetaminophen/Tylenol), possibly mixed with alcohol. Normally the patient will arrive via ambulance after they realize the error in their actions. Or sometimes, it’s after a friend or family member reads between the lines of their text messages and calls an ambulance. The patient normally arrives numb and is compliant with our interventions.
Once the patient is deemed medically fit, a mental health evaluation is requested. Within an hour of the referral, a registered mental health nurse (RMN) such as Amy, also known as a mental health liaison, will come and assess the patient. For myself, as a staff nurse, seeing it from the outside, it looks like a mini-therapy session. The RME assesses the triggers that brought the patient into the A&E. Most importantly, the RMN assesses their mental capacity and whether the patient is at risk to themselves.
Mental Capacity
The patient that comes to mind is a person with multiple recent stressors. A recent breakup, layered with a loss of job, previous childhood trauma, and no social safety net. And at that moment found their life to have no purpose. In an impulsive action, they swallowed the contents of the medicine cupboard and washed it down with alcohol. Either through their own regret, or by reaching out to someone, help was called and they arrived at the A&E.
At the moment of their actions, their emotional distress caused them a lack of mental capacity. After getting treatment in the A&E, and at the point the RMN is evaluating the patient, they may have gained mental capacity. And most times will be discharged with a referral to community resources. But how can someone who earlier wanted to end their life be safe to go home?
In England the answer lies in the mental capacity act (MCA).
“People can lack capacity to make some decisions, but have capacity to make others. Mental capacity can also fluctuate with time. Someone may lack capacity at one point in time to make a competent decision, but may be able to make the same decision at a later time.”
The National Health Service
Amy in her gentle manner assesses the triggers that lead to their actions. She takes into consideration the emotional distress or ambivalence towards their actions, which can be deemed to lack mental capacity, prior to making a final recommendation. But if the patient can restate their actions, understand them and the consequences, and realizes the triggers that lead to the events and the fault in their action, the patient has mental capacity. As Amy recalls “a mother furiously called me after I had discharged her daughter. It’s always hard to explain to the family that the patient had mental capacity. That they understood the consequences of their actions.” She continues in a solemn tone, “I cannot hold someone against their will just because they wanted to harm themselves. They must be willing to accept the help.”
The Ethics of Mental Capacity & Mental Health
In my conversations with Amy, she confirms the importance of the mental capacity assessment. “It has to be rock solid, it is the corner stone of our treatment. If something happens to the patient, you must be able to stand your ground in court. You cannot hold a patient against their will if they have mental capacity.”
I have seen patients with suicidal thoughts, no plan of action, discharged with referral to outside resources, and I wondered if they will stay safe. After working over a decade in the USA it is hard for me to see these patients go home in a similar state as when they arrived.
But back home (USA) I also recall the ED over half full of mental health patients on “hold” for days waiting for the appropriate resource to become available. Holding patients against their will, days after the crisis had resolved. In a windowless room no less, with minimal consideration to potential emotional triggers that might be brought on by the isolation. It is a different method of treatment here in England, not better or worse, just different.
England does realize however the gap in treatment. A gap which is currently being filled by charities, such as Maytree Suicide Respite Centre. Maytree offers free respite stays for people in suicidal crisis. These organizations provide support for patients who are at risk of suicide, but have mental capacity.
A patient who is discharged, is not set loose in the community. An important part of the assessment is figuring out their level of risk. And the resources they will need and be provided once they are discharged.
The Assessment
Amy completes the mental assessment within the hour and determines whether the person is a low, medium or high risk to themselves. In addition, she also determines the cause of their distress, which will guide the treatment plan. A raped victim will have a different treatment plan as compared to someone going through grief, even though both patients may have attempted suicide. Part of the assessment is getting to the root cause. Specialized resources are available for rape victims, post-traumatic stress disorder, eating disorders, grief groups, and anxiety, just to name a few.
A low risk patient
A patient at low risk will be provided with a self-referral to group therapy, cognitive behavioral therapy, in person, or online (iTalk,). A full initial assessment will be completed ideally within one week by the community mental health team.
An important resource is group therapy that focuses on teaching patients appropriate coping skills or strategies. An important tool to have prior to starting one-to-one therapy and having work through deep emotional wounds.
Medium Risk Patient
A medium risk patient will be contact by the community health team. Depending on acuity, as soon 24 hours or up to a week after being discharged from the A&E. The team is composed of a RNM, social work, and psychiatrist. The patient then gets reassesses and provided the resources necessary based on their needs. The social worker may also assist the patient with accessing services they may be entitled to such as housing or assist with their employment. While the psychiatrist will provide any acute medication needs.
High Risk Patient
A high risk patient will get assigned an acute mental health team. Which is a 24 hour service and works alongside the community health team mentioned above. The team is known as ‘hospital at home.’ Services includes medication at home and creating a safe home environment to treat the patient. The idea is, there is greater chance of recovery, even in a state of crisis, when the patient is at home. The safety of their home environment can facilitate recovery, or the opposite. It can also alert the medical team of triggers that need to be addressed.
The recurrent patient
In any A&E, you have the regulars, aka frequent flyers, or more politically correct, a high frequency user. This is the patient who comes in with a mental health crisis but knows you just got your hair cut. Normally they are lonely and have come to see the A&E as a safe place. In the USA, this patient finds a community in the emergency room and, at times, it is their only community.
But in England it is a bit different since these patients have community resources in place which are less available in the USA. The care-seeking behavior the patient often at times presents as parasuicidal. This behavior in England is not encouraged by the RMN. Amy lets me into the mini-therapy session she has with the patient in which she inquiries about their behavior. She asks what happened that day and what barrier they had preventing them from using coping skills they have been taught in therapy. High frequency users are promptly assessed and discharged. The goal and encouragement for them is to use the community resources already in place for them.
Lack of Mental Capacity
The patient that arrives in acute psychosis, lacking mental capacity, can be detained under the Mental Health Act. The term used here is holding a patient “under a section 2.” People detained under the Mental Health Act need urgent treatment for a mental health disorder. These patients are at risk of harm to themselves or others. A section 2 detains the patient for up 28 days, allowing for in hospital assessment and treatment in acute phase.
Under a section 2 the patient will receive medical treatment whether or not they consent to it. But if the health team determines the patient has gained mental capacity, the patient can be discharged prior to the 28 days. If treatment is required past 28 day, the patient is placed under a section 3; which can be up to 6 months detainment in hospital for treatment.
Mental Illness versus Addiction
My observations in the treatment of mental health in England has expanded my perspective. But one disappointing difference is the distinction made between mental illness and addiction, treating them as two separate entities. Amy has had to advocate more than once for appropriate treatment for patients with addiction. The battle lays in two of the division of resources for patient. A patient with history of intravenous drug usage will fall into addiction sector. Mental health services will not see the patient until they are drug free, “clean.” But, the reality is that they require mental health treatment to get clean. This type of separation causes poor patient treatment. Addiction and mental illness overlap and in my humble opinion cannot be separated.
After the crisis
After the assessment, the crisis normally passes and the patient is discharged home. And provided with community resources. A patient in a mental health crisis is at a turning point and with the help provided by the RMN is usually guided in a better direction. Amy works hard to help each patients find their own answers, guiding them to appropriate care. Maybe, like Amy, we have to Trust the universe a little bit more and let the people in crisis guide us to the care they need.
Mental health is a vast concept with many branching off points. It is impossible to sum it up in two posts. But I do hope my observations have allowed you to see how things can be done differently. We can learn from one another to provide better treatment to those in need.
Photo Credit Andy Blakemore
