‘Working in a crisis service is a constant source of growth’

It takes, on average, less than 20 seconds for a Child and Adolescent Mental Health Services Single Point of Access clinician to respond to a crisis call. As such clinicians, we pick up not knowing what the call will be about. Every day, our team receives crisis calls from young people and their families, most often at moments when emotions are at their highest; it could be a young person who has just harmed themselves, a terrified parent or a teen in the grips of a panic attack. Uncertainty and unpredictability are ever-present. 

Our Single Point of Access (SPA) for CAMHS (Child and Adolescent Mental Health Services) operates 24 hours a day, seven days a week, 365 days a year. The team consists of trained clinicians who provide urgent mental health support to young people and their families over the phone, and administrators who are experienced and well-versed in processing referrals to various teams. A typical day involves handling crisis calls, triaging, referring patients to appropriate services for ongoing support and ensuring service users experience seamless transitions between mental health services.

Each call is unique. Often, you are the first mental health professional to have spoken to this young person. To be their first contact with mental health services is a big task – it might shape their long-term relationship with mental health services. This is a big deal, because the increasing mental health challenges faced by young people are well-known, with suicide being one of the leading causes of death among this population. In England, 25 per cent of 11-16-year-olds and nearly 50 per cent of 17-19-year olds with mental health disorders report having self-harmed or attempted suicide.

These statistics show how important it is that young people receive support not only in moments of crisis, but as a consistent part of everyday life. Our communities have to foster an environment where young people feel safe to express their struggles before they escalate – early intervention is incredibly important.

This is where THRIVE, the model CAMHS SPA is based on, comes into play. THRIVE has four quadrants – Getting Advice, Getting Help, Getting More Help and Getting Risk Support. CAMHS SPA sits across all four quadrants fostering a continuum of care aimed at early intervention, preventing crisis and minimising the risk of future occurrence. 

A sense of safety

Alongside all the other lessons the Covid-19 pandemic taught us, it also underscored the importance of being a flexible, adaptable service. This comes with its challenges – absence of face-to-face contact takes away the ability to pick up visual and non-verbal cues. CAMHS SPA practitioners must pay close attention to all the nuances of verbal communication, adjusting their approach when they detect signs of distress or escalation. However, some young people may even prefer telephone contact, especially those with moderate to severe social anxiety, as it reduces the intensity or pressure of in-person interactions.

An important aspect of being a crisis practitioner is creating a sense of safety for the young person. The clinician's priority is to build rapport with the young person while gathering critical information for risk assessment and management. Maintaining a calm and grounded presence is crucial for clinicians during crisis calls, no matter the novelty of the situation. This sense of calm can act as a form of co-regulation, where the clinician's emotional stability fosters a sense of safety for the young person. The therapeutic relationship, guided by this calm, creates a foundation for emotional stability (Butler & Randall, 2013; Geller, 2017). 

The concept of remaining calm in a crisis isn't just about emotional restraint; it's rooted in psychological research. Stephen Porges' Polyvagal Theory explains that the human nervous system is highly sensitive to cues of safety or danger, even in the absence of physical threats. When a young person in crisis hears the steady, calm voice of a clinician, it can help regulate their nervous system, shifting them from a 'fight or flight' response to a state of greater calm and openness. This process of co-regulation – where the emotional stability of one person helps regulate another – is essential in mental health crisis work.

Apart from being a walking directory of various mental health services available in the area, as a crisis clinician, you are also a practitioner that does various types of risk assessments. Working in a fast-paced, telephone-based crisis service requires an understanding of both biological and environmental factors influencing risk. Clinicians enquire about access to substances and medication during every contact; however, we also explore all other possible factors. The Diathesis-Stress Model, which highlights the interaction between genetic predispositions and environmental stressors, is particularly relevant in crisis situations. For example, a young person with a genetic predisposition to depression might engage in self-harm following cyberbullying or peer rejection. Neurobiological factors, such as serotonin imbalances in conditions like Autism spectrum disorder (ASD) and Attention deficit hyperactivity disorder (ADHD), are linked to impulsive behaviours, further increasing the risk of self-harm or suicidal ideation (Barkley, 1997). Managing these risks involves developing a safety plan with the young person and their family, focusing on both immediate and long-term safety measures. 

Understanding these factors is critical, not only for clinicians but for everyone involved in supporting young people. We can't always prevent a crisis, but we can create environments that reduce their likelihood. That means fostering open communication, reducing the stigma around mental health, and being vigilant about the impact of social media and peer relationships. 

Risk assessments around social media use are also imperative. Social media plays a significant role in exacerbating mental health challenges, with young people often exposed to idealised images of others' lives, fuelling feelings of inadequacy. Platforms like TikTok can normalise harmful coping mechanisms, leading to an increased risk of self-harm. While social media can offer a sense of connection and belonging, it can also increase feelings of loneliness and depression (Khalef et al., 2023).

The best care possible

With both of us having previously worked in community settings, a difference we note between community and crisis services is that there is rarely capacity for preparation before a crisis call. For triages, there is room for preparation; however, with most of our triages being attempted within 24 hours, this is done fairly quickly before moving onto another. This fast-paced environment was a significant adjustment from therapy-based settings, where we had a week to prepare between sessions. We have learnt to trust our clinical instincts and lean on teamwork when unpredictability arises. What matters most is being fully present in every interaction and providing the best care possible, one call at a time. 

To be a clinician supporting acutely unwell individuals on every shift means showcasing the same compassion and concern towards yourself. Ellis et al. (2018) wrote about the importance of self-care for clinicians who work with suicidal patients, stating that forgoing self-care as a clinician can lead to poorer care and countertransference, among other issues. Boundaries have been an important part of this for us, such as not checking work emails outside working hours and asking for support. Rejuvenating between work shifts is incredibly important. Holistic health and wellbeing is vital in order to stay grounded during difficult days at the service as well as discussing difficult referrals and crisis calls with other clinicians and bringing cases into supervision to reflect upon has helped foster coping abilities. 

With our work life occupying many hours of our week, fostering meaningful, supportive and even enjoyable relationships within that large chunk of our week has always been important for us. Building friendships in the workplace can create a sense of community, contributing to both personal wellbeing and service success, as well as enhancing teamwork, productivity and organisational culture. We value that our colleagues always listen, no matter how busy their day is. Working on a 24/7 shift pattern means you do not meet your entire team often, hence when we do, it is a moment we truly appreciate. 

It is often said in our workplace that crisis services attract a certain type of clinician – ones that seek adrenaline, that welcome chaos and that can thrive in a challenge. It also demands a clinician who is adaptable and flexible. Edward (2005) conducted research on what makes crisis practitioners cope in highly demanding, stressful and complex environments. The study found resilience was identified through one's team, sense of self, faith and hope, having insight and looking after yourself. 

Steady presence in uncertainty

For us, unpredictability and challenges mean learning throughout, having to adapt continuously and becoming versatile clinicians. The experiences at CAMHS SPA are positively challenging and deeply rewarding. We have all heard that being a clinician means learning and studying every day – every patient contact is an opportunity to learn and develop. We see working in a crisis service as a constant source of growth. When it comes to crisis work, the best way to handle unpredictability is to embrace it. No one comes into crisis work expecting predictable work – if you did, what were you thinking?! 

As CAMHS SPA clinicians, we have found that no two calls are the same – one moment we could be offering guidance to a parent overwhelmed with their child's behaviour, and the next we could be de-escalating a crisis that involves a young person who has self-harmed or feeling suicidal. Each interaction requires us to think on our feet by being pragmatic, adjusting our approach and adapting our communication style, as well as remaining grounded, no matter how unexpected and challenging the situation becomes. 

While the nature of our job can be demanding, it's also deeply rewarding. Knowing that we have provided comfort and clarity even in a brief encounter, makes every challenge worth it. Adapting continuously to meet the needs of those we serve has taught us that creating safety isn't just about resolving crisis – it's about being a reliable, steady presence in moments of uncertainty. 

For clinicians, working in a crisis service involves facing daily uncertainty. However, the strength of the team – managers who are available, colleagues who listen, and a shared understanding of the challenges – provides the support we need to continue this vital work. Caraballo's research in 2013 asked an interesting question – what keeps a crisis clinician in their job? The connections made with patients and within the team are what define us… that's what has shaped us into the clinicians we need to be.