Information for carers and relatives dealing with a mental health crisis

Planning for an emergency / crisis

Crises can happen at the most inconvenient times, including late at night or over a weekend. At such times it is not easy to respond in the best or most appropriate way. It is helpful therefore, to try to think about some of the worst case scenarios in advance, how you might respond, who you might call on and where to keep this information safe and handy. In this way, if things do get difficult, you have some sort of plan set up to help you through.

You will need to know the numbers of out-of-hours services that are available in your area and have them by the phone or in the phone book. Similarly, you will need the numbers for relatives and friends who can be called on at short notice, either to give you support in your home or, if you have to go away, support for those left behind. This is especially vital if it is you who has an accident or crisis rather than a relative or friend with a mental illness.

Contact numbers for all services involved in your relatives’ care, and others who support you, should be kept with you at all times. With agreement, they should also be written in to your relatives’ notes so that they are readily accessible to any persons who might need them.

These plans should be drawn up and agreed by you and the relative/ friend you provide care for when that person is calm and in a stable condition so that everyone is clear about what will happen. Having a contingency plan can also be helpful in avoiding a really serious crisis.

It’s also important to think about drawing up a confidentiality agreement or an advance statement or directive. If you are the person responsible for your relative/friend being sectioned or admitted to hospital voluntarily, you will possibly be the last person they wish to be told about what is happening to them.

Patient confidentiality can sometimes be a source of irritation when your relative is unwell and staff won’t give you information. If you are likely to be someone helping with your relative or friend’s care when they leave hospital you will obviously wish to be informed about what is happening, how things will be managed in the future and how you will be included in the process.

You may need to find some way of encouraging your relative or friend to include you in the discharge planning, helping them realise that you will be a useful ally in their care. In order for the agreement to carry weight with the professionals you need to ensure that you have discussed it thoroughly with your relative or friend have it documented in the service users’ notes by a mental health professional. It will probably be a more acceptable arrangement for your relative or friend if they feel that some pieces of information are retained as being confidential e.g. discussions in therapy groups or individual counselling sessions or seeing their records. In this way they can still maintain control while at the same time allowing you access to information it would be useful for you to know. This is beneficial for all parties and ensures that professionals do not breach any of their guidelines.

If you are registered as a Carer it is good idea to sign up for an Emergency Response card with Lincolnshire County Council. This gives other’s directions of what to do if you are unable to care for your loved one due to an Emergency Register yourself with your GP as a carer. GP’s should hold a register of anyone who is a carer for someone else.
 

Top tips when talking to a health professional

• Be persistent. If you feel there is a need for someone to intervene then say so
   
• If staff say they cannot share information with you due to confidentiality or lack of consent this does not stop the health professional listening to your concerns
   
• Ask staff what you should do. Ask how to get a referral to a service that you feel your loved one needs
   
• Ask for the telephone or contact details of service referral criteria

Talking to someone with strange beliefs or delusional thoughts

A delusion is a false belief that cannot be swayed by concrete evidence. A hallucination is not a delusion or a false belief. Hallucinations are sensory perceptions involving any of the five senses. One of the most common ones is hearing voices. Hallucinations may also be evident in a number of illnesses as well as schizophrenia, probably the most common being high temperatures from infections (especially in the young and elderly) or withdrawing from alcohol or drugs.

The term psychosis is used when the person loses touch with reality and may be suffering from hallucinations and/ or delusional beliefs.

Don’t dismiss the delusion – recognise that these ideas and fears are very real to the person but also do not agree with them e.g. “ I don’t believe …… is out to get you but I can see that you are very upset about it”.

Don’t act horrified by bizarre words or unfinished sentences. Say “I don’t really understand what that means” or remind them of the conversation you were having and distract them back.

Don’t let others laugh about the delusion, hallucination or strange talk. This can increase the person’s agitation

Acknowledge the persons distress – say something like “I can see you are very upset. How can I help you?” This is reassuring to the individual and gets a rapport going.

Aim to be positive and comforting rather than negative or emotional. This can be hard to do but do not show annoyance or criticism.

Don’t promise everything will be okay. Acknowledge there is a problem but reinforce there is help available.

Try to have a contingency plan in place in times of crisis so you know what to do. This can help reassure you and help you keep calm when dealing with the situation.

If you think someone is suicidal as there is a change in usual behaviours let someone know. You can contact the person’s care coordinator or contact an emergency crises team. The contact details of any crises contact should be documented in a crises and contingency plan.

Don’t ask the person to try to force the voices to stop.

Do act calm.

Do try to distract by involving them in something interesting. Go to look for something with them, chatting
about everyday things and involving them with close friends/family.

Do give the person time and space if they do not want to talk. Say “I can see you don’t want to talk now, but I’ll be here for you if you want to talk later”. Allow time for them to recover their pride, their thoughts and their composure etc.

Do find someone to talk to, to let off steam yourself – another carer, a support group, a professional – anyone you feel comfortable with.

Dealing with difficult behaviour

Below are tips shared from carers to help you deal with difficult behaviour:

• Don’t act impulsively – talk things through
• Don’t invade personal space and stay at arm’s length
• Avoid putting yourself in a corner
• Always knock
• Get to know the signs – pacing, rocking, fist clenching
• Keep neutral body posture
• Keep hands in sight – show the palms of your hands
• Don’t clench your fists, put hands on hips, stare or point
• Make eye contact – but don’t stare. Smile.
• Be self-aware
• Be calm – walk slowly, don’t show agitation or irritability
• Empathise – “I think I know how you feel.”
• Sympathise – “I agree with you.”
• Ventilation – let someone get it off their chest. Don’t interrupt or argue.
• Get them talking – use open ended questions such as “How did that feel?”
• Avoid physical contact
• Set ground rules – let the person know the limits and consequences
• Know who to call in an emergency
• Don’t get involved in a pointless argument
• If they storms off, leave them to cool down before talking to them – don’t try at that time
• Take a break – Give time for you

Dealing with self-harm

People injure themselves for many reasons. It can replace emotional distress with physical pain. Many people say that when they cut themselves they experience a release of tension and so they often feel calmer. In a strange way self-injury may help people feel that they can achieve some degree of control
in their lives.

Self-injury is very often not a suicide attempt; however people who do self-harm are at a greater risk of suicide than the general population due to their high risk behaviour. They should not just be seen as “attention seekers” or “manipulative”.

Relatives, friends or professionals trying to help the person can find it very stressful, especially when the person does not want to talk about or explain their behaviour. It is easy to feel ‘shut out’ and just left to pick up the pieces when in crisis.

If someone we care about is deliberately damaging themselves and not willing to let us help we feel
isolated and powerless. The person usually has very low self-esteem and poor self-worth, or they may be
in a state of psychosis, and they think that others will see them in the same light and be critical of them.

There are therapies that can be used that have been shown to be effective in breaking the negative cycle of self-harm.

Below are some steps you can take when dealing with someone who self-harms:

• Respond to an incident of self-harm in the same way that you would for an accident. Give first aid as you would for any physical injury.
   
• Do not assume that the person either enjoys or does not feel pain. A response which implies criticism or some form of punishment simply reinforces the persons feelings of guilt and self-blame.
   
• Acknowledge the persons distress – say something like “I can see you are very upset. How can I help you?” This is reassuring to the individual and gets a rapport going.
   
• Aim to be positive and comforting rather than negative or emotional. This can be hard to do but do not show annoyance or criticism.
   
• Don’t promise everything will be okay. Acknowledge there is a problem but reinforce there is help available.
   
• Try to have a contingency plan in place in times of crisis so you know what to do. This can help reassure you.
   
• If you think someone is suicidal as there is a change in usual behaviours let someone know. You can contact the person’s care co-ordinator or contact an emergency crises team. The contact details of any crises contact should be documented in a crises and contingency plan.

LPFT Carer Leads

All wards and teams within the Trust have a Carer Lead.

The role of the Carer Lead is to:

• Develop greater awareness of carers within the team, supporting colleagues to routinely identify and be sensitive to the needs of carers of all ages.
   
• Promote good practice and partnership working with carers; communicating directly with carers and supporting them to access appropriate meetings, raise their concerns etc.
   
• Develop and maintain systems and processes that actively support the identification and support of carers.
   
• Ensure that colleagues understand the value of working with carers.
   
• Ensure that there is relevant and update date information available to carers.
   
• Endeavour to undertake ‘Family Work Training’ where possible.

If you know which team your relative is under it is worthwhile contacting the team and asking who the Carer Lead is as they may be able to advise you on what to do in your particular situation.

Role of Nearest Relative

A Nearest Relative (NR) is a legal term relating to a person who has responsibilities and powers under the Mental Health Act (MHA) 1983 (Amended 2007). A Nearest Relative is not the same as a person’s Next of Kin (NOK), which is primarily a term used in reference to a relative or someone who is nominated to be informed about a person’s medical condition or treatment.

While next of kin do not have any rights under the MHA, nearest relatives have the right to ask for a MHA assessment, the right to apply for an admission and the right to request discharge.

Following a MHA assessment and a decision to detain a person to hospital and under some other sections of the Act, such as Guardianship, nearest relatives are identified and contacted by an Approved Mental Health Professional (AMHP) for their views regarding the person’s situation / hospital admission.

While the nearest relative has some rights they do not have any extra rights to be given information about their relative’s mental health care or treatment; there remains a duty of confidentiality which requires a person’s consent to share information.

Under some sections of the Act the NR must be consulted. An AMHP will take such steps as are practicable to inform the NR an application is being made and inform the NR of their powers under the Act. The AMHP will refer to the MHA and also the MHA codes of practice for due process should a reason not to consult be identified.

The role of a nearest relative is an important safeguard for people who are subject to the MHA to ensure a person’s rights are protected and to also act in the role of advocate for the person.

Looking after yourself

It’s important to look after yourself. If you are not well, either physically or emotionally, then it makes it very difficult for you to care for someone else. If you are struggling yourself it is important to seek help. Below are a few tips that you may find useful to support your own wellbeing.

• Take time for yourself and do something that you like, even if it is for 30 minutes or an hour a day (e.g. read a book or have a relaxing bath).
   
• Find someone to talk to. Having a friend or peer to offload to can be really beneficial to your own mental health. You could also join LPFT’s carers WhatsApp group, which consists of LPFT carers who support each other and will understand what you are going through.
   
• Join LPFT’s carers education and support group and learn about your relative’s condition, how services are run, and meet others in similar situations to you.
   
• Email the LPFT carers email address and let us know that you need some support - lpft.carers@nhs.net
   
• Ask about family therapy available through the Trust.
   
• Take courses through our Recovery College. There are lots of courses suitable for carers.
   
• Remember our Mental Health Helpline or the Samaritans are also available if you need support.

To join the WhatsApp group or carers education and support group email donna.bradford@nhs.net.

Useful contacts

Lincolnshire County Council Customer Care Centre:
customer_services@lincolnshire.gov.uk / 01522 552222
(Phone lines are open Monday—Friday, 8am to 6pm)

Lincolnshire Young Carers:
01522 53275 / youngcarers@lincolnshire.gov.uk (Young carers are able to access a young carers card through the service, which helps raise awareness with professionals that they are involved in someone’s care and to facilitate conversation around diagnosis, prognosis and medication)

Dementia Support Service:
0808 506 2558