‘What may seem like chaos from the outside is in fact a deep well of knowledge and wisdom from the inside’

Shortly after graduating with my psychology degree I started applying for jobs in mental health services. I imagined myself sitting in a room with a patient, delivering weekly therapy sessions, listening to their difficulties, and helping them to make positive change that would improve their life. With a sense of real excitement, I accepted the first job offer I got as an Assistant Psychologist in the Crisis Resolution and Home Treatment Team in Reading, Berkshire. It's a short-term and intensive 24/7 service for people experiencing mental health crises, bringing hospital-like treatment into the community, and preventing hospital admissions when it is safe to do so. Little did I know how the journey ahead would change me…

I remember going with a nurse to complete an initial assessment of my first patient, after she had contacted the team expressing the desire to end her life through an overdose. Soon after her call, we were waiting at her doorstep. She invited us into her flat with a gesture of her hand, without saying a word. As we sat down, she burst into tears and started apologising for wasting our time. She reached for tissues to blow her nose, and I noticed her forearm covered in old scars and fresh cut wounds, which she tried to cover as she realised her sleeve had rolled up.

For a moment, I froze and started questioning myself on whether I had read the correct notes before seeing her. According to the notes, she had a stable and secure job and there was no history of previous involvement of mental health services in her care. We only knew that her fiancé had left her just days before she contacted our team. We sat with her, reassuring her that it was ok to cry, that she was safe. Once she had no more tears left, she started sharing her story – a painful history of bullying, abuse, dysfunctional family, and abandonment which resulted in self-hatred and lack of sense of belonging covered by long hours and extra shifts at work, where the focus was on others. Forced to use her annual leave, her wall of defence fell.

Falling apart

Two hours later, we were leaving her flat with a bag of medication and a box of sharps ready to dispose of, and a safety plan created with the patient. I felt stunned, angry, and sorry for the injustice and suffering she had experienced. But I soon realised that I would listen to similar stories more frequently than I had ever imagined.

Looking back, I can confidently say that I have grown, and I feel grateful that I was given the opportunity to work in this team before moving to a different service. Seeing your patients falling into pieces in front of you and supporting them to hold those pieces until they are ready to start putting them back together, is a feeling that I can't describe with words – but it is one that has shaped me as a clinician.

However, during my time with Crisis, I was struck by colleagues expressing the view that the chaotic crisis environment left little opportunity to implement evidence-based psychological therapies. Perhaps they were right in a sense, as it is nearly impossible to provide a full course of psychological therapy to a person experiencing a mental health crisis and whose world is falling apart. And I agree, it may feel chaotic. But what may seem like 'chaos' from the outside is in fact a deep well of knowledge and wisdom from the inside, patiently waiting to be discovered if you are brave enough to enter into the 'chaos' with your patient, side by side. My perception of what therapy can actually look like has changed dramatically.

Space to share

The truth is that working in a front-line mental health service is incredibly challenging, unpredictable, fast-paced and very demanding. I remember my first few days and weeks, feeling quite lost and overwhelmed with new patients being referred every day, each presenting with a different severity and combination of symptoms of different disorders and mental health issues, the majority presenting with a very high risk of self-harm or suicide, hopeless, angry, and desperately looking for help. I came across patients suffering with a huge variety and severity of mental health conditions.

Early stages of crisis intervention in the crisis team focused mainly on medical treatment, e.g. looking at presenting symptoms, clarifying diagnosis, prescribing medication. Working closely with psychiatrists and mental health nurses was a great opportunity to learn interesting and important facts about mental health, and increase my knowledge about psychiatric disorders, symptomatology, psychotropic medications and their side effects, and recommended treatments, both medical and psychological. This knowledge, not always recognised as significant in the world of psychological therapies, contributed to my understanding of the person in relation to a biopsychosocial perspective.

As an Assistant Psychologist my role was to look beyond symptoms, to create a safe space for patients, to establish a therapeutic relationship, to gain their trust, to allow them time to tell their story without being rushed, to enable their voice to be heard, to give them space to share their anger, pain and suffering, to formulate their needs and difficulties, and to help them make sense of their experiences.

Sense of comfort

The first step was to just listen. Stop the urge to try and fix things or to give solutions. By listening and gaining insight into their experiences across their lives, I was more able to see the world through their eyes. I could see how, for example, taking an overdose wasn't an 'attention-seeking' behaviour, but instead an action leading to receiving care by someone who had not received that care in their childhood; staying in an abusive relationship wasn't about 'making the choice to stay', but about finding a sense of comfort that comes with predictability for someone who grew up experiencing or witnessing abuse; self-harming wasn't just a 'maladaptive coping mechanism', but a safe way of expressing emotions for someone who grew up in an emotionally invalidating environment or who was punished for showing anger or frustration in their childhood. Sharing this understanding with patients and checking the validity of the beliefs resulting from these experiences in the present was the next step.

Daily listening to heart-breaking stories of patients, empathising with them, acknowledging their despair and hopelessness, listening to their frustrations, and allowing them to feel and express their emotions without judgment were the foundation of creating that safe space they so desperately needed in crisis. Medication was helpful in reducing some of the symptoms, but rarely the complete answer.

Ice cubes or cold water

I've learned that every patient has their own unique story, their own way of coping and needs an individualised approach. Where some may benefit from a slower and more gentle approach, others may need a much more assertive style, with clear boundaries and rules. By exposure to such a huge variety of presentations, I quickly gained a much better understanding of the complexity of the human mind. There was no one recipe for treatment. Working in the crisis team taught me to be flexible in my approach, to think quickly and creatively, and to think outside of the box. I learned to adapt therapeutic interventions and draw on a variety of different therapeutic approaches depending on what that one patient sitting in front of me needed at that point in time.

Drawing from DBT therapy, I worked with people on developing distress tolerance skills through using basic physiological changes to identify emotions and reduce their intensity, e.g. linking increased body temperature and fast breathing with anxiety, and using ice cubes or cold water to initially reduce body temperature, followed by soothing rhythm breathing to calm the brain down and get out of a threat mode. The work consisted of helping people to increase their awareness of their emotional world, naming their emotions, communicating them to themselves and others, at the same time increasing their understanding of their experiences and ability to tolerate their emotions more effectively.

Others needed a more compassion-focused approach, learning ways of developing a more gentle and compassionate inner voice and reducing the sense of guilt, shame and anger. I frequently used strategies from a solution-focused approach, shifting people's attention from the problems to solutions, from patterns of behaviours that were unhelpful to actions and behaviours that had a positive impact on maintaining the stability of their wellbeing; instead of trying to e.g. 'get rid of depression', encouraging them to focus on their values and create goals that were of personal significance in their recovery and increased their sense of connectedness. With those patients who were past their crisis point, I could work using CBT based interventions, helping them to address their negative beliefs or modify behaviours through cognitive challenging and behavioural activation.

Between the gaps

Working in the crisis team also gave me an opportunity to facilitate brief group interventions, eg. depression groups and solution-focused groups. Another valuable experience gained from my role was working with our patients' wider systems, facilitating a support group for their family members and friends. This helped me to understand how the mental health struggles of one person can have a ripple effect on a huge number of people within their families and social network. It also helped me to understand the anger and frustration frequently expressed by patients and their families, who often found themselves suffering for years and falling between the gaps of already stretched mental health services, feeling stuck in a cycle of self-destructive behaviours and relationships, and unable to break the cycle of pain by themselves.

Being an Assistant Psychologist in a Crisis Team has many challenges, and was life-changing for me. It is a place where you have a chance to expand your knowledge and understanding of the complexity of mental health and the human mind, and the role of psychology within that setting. You learn to be open-minded, curious, and to never make assumptions. These varied and challenging experiences built a foundation of knowledge and transferable life skills – including negotiating, quick decision-making, flexibility in thinking, assertiveness and resilience –which I have taken with me into my new role.

- Adriana Lisowski is an Assistant Psychologist at Integrated Psychological Therapies Service
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