There has been ongoing debate in the occupational therapy literature about whether occupational therapists are best placed to work with service users in crisis outside the confines of hospital (Rosenfield,1984; Miller & Robertson,1991). In the UK, policy has recommended a change of focus away from treating the majority of clients in crisis in the hospital environment to alternative settings and home treatment (Department of Health, 2001). Policy in the US, Australia and Canada has also taken this direction (Polak & Kirby, 1976; Miller & Robertson,1991; Gage,1995; Lloyd et al., 1999). There are multiple reasons for this change in the management of service users. Some of this has been as a response to service users’ preference for alternative treatment options, allowing them a greater input into what happens when they experience a crisis. Another key consideration is finance, enabling money previously spent on in-patient bed days to be redirected and used more cost-effectively in alternative community service provision. Socially, interventions provided in the community allow for greater involvement of the people important to the service user, whether these are friends, family members or health care professionals.

Although the benefits of these changes are recognised by occupational therapists, there is ongoing deliberation within the profession regarding generic versus specialist roles, especially when working in the community (Parker, 2001; Cook, 2003; Harries & Gilhooly, 2003; Harrison, 2003). A search of the occupational therapy literature demonstrates that there is no discussion of this area of practice in relation to in-patient and community crisis work, and what these emerging roles may look like or how therapists would experience these.

It is often considered that crisis intervention posts involve non-traditional or extended scope practice, which are frequently considered as generic. Take-up of these posts is not only a choice for the profession as a whole but also for the individual practitioner. However, there are specialist skills associated with these roles, and occupational therapists need to acknowledge that they may have developed these skills as part of their existing clinical experience and can transfer them into these alternative settings and situations.

In all areas of occupational therapy it is likely that practitioners will encounter service users at a stage of crisis or when they have to adjust to the impact of crisis on their occupational performance. This may be a traumatic injury, a loss or a relapse of illness; whatever the cause, when considering a person in crisis, the occupational therapist reflects on how a crisis impacts them as individuals and their occupational functioning in their environment. Working with service users in an acute mental health crisis is no different, and employs the same skills. It is acknowledged that most crises for service users in mental health are a result of social or emotional stressors. Therefore, the management of a crisis is not necessarily defined by symptoms that require a medical approach to deal with them. The person in crisis may find ways to resolve his or her problems or may find it increasingly difficult to deal with the situation that causes further disruption to his or her daily life, the things that are important to him or her and his or her ability to maintain their usual routines. The ability to assess the service users’ needs at the point of crisis, working alongside them to resolve the crisis and ensuring their return to health, are familiar to most occupational therapists.

Caplan (1964) is widely cited in the literature for his early recognition and definition of a crisis. He described four phases of a crisis:

• Phase 1 – Tension mounting.
  
• Phase 2 – Increasing disorganisation.
  
• Phase 3 – Mobilisation of all internal and external resources.
  
• Phase 4 – Major disorganisation or maladaption.

Later, Onyett (1998, p. 156) further elaborated these phases as follows:

These descriptions will be familiar to occupational therapists, especially those working in acute in-patient units, who are likely to have encountered service users at both stages three and four of a crisis. The Mental Health Foundation (2003) asked service users how hospitals helped at times of crisis, what coping strategies were used to reduce mental distress and what could the hospital do better to help them cope. Service users reported that activities that motivated them were helpful but that ‘the need for sanctuary during times of crisis is jeopardised by the poor relationship between staff and patients’ (p. 3). Significantly, they also identified that service users were not being provided with appropriate and timely support at times of crisis. Lelliot and Quirk (2004), in reviewing the literature on acute hospital admissions from several countries, highlighted that one group of inpatients in Norway had identified their common needs on admission as being ‘security, sleep, rest and help with finding meaning, which includes “new tracks in life” and an ability to cope better with difficult situations’ (p. 299). Both these studies emphasised the need for timely support in an environment to sustain the service user in crisis, whether it is an in-patient unit or at home. With the introduction of crisis resolution/home treatment teams, there has gradually been a change in the needs of the service users admitted to in-patient units, resulting in more intensive input from all staff members in the unit. Importantly, there has also been a general reduction in length of stay for service users, which decreases the likelihood of dependency but may leave individuals feeling insecure and unsupported in the community.

Crisis intervention teams

Crisis intervention teams were established to ‘prevent where possible, hospitalisation, deterioration of symptoms and stress experienced by relatives/others involved in the crisis situation’ (Hopkins and Wasley, 2002, p. 18). Birchwood et al. (1998) discussed the value of working with service users to identify their relapse signatures, identifying their early warning signs and using them to prevent, where possible, complete relapse and admission to hospital.

Dealing with crisis in the home environment is usually seen as preferable for service users. However, a study on referral patterns to crisis resolution teams followed up service users subsequently admitted to hospitals. It demonstrated that there remained a group of service users who chose to be admitted to hospital rather than to receive treatment at home (Brimblecombe, 2000). This aspect was not investigated further in the study, but it may be that these service users only feel safe away from their home environment at such times of crisis. As hospital admission has been the usual response for service users in crisis, a change in approach may take some time to be accepted by service users and staff alike.

In-patient units

The state of in-patient mental health units and the service they provide in England has been widely criticised [The Sainsbury Centre for Mental Health (SCMH), 1998; Ford, 1999; Campbell, 2000; Dratcu, 2002]. Recent reviews of in-patient care report only limited improvement of facilities and services available to service users. Occupational therapists, in a study by Simpson et al. (2005), expressed their frustration at service users either being too ill to engage in activities or being discharged just as they are engaging fully in therapeutic activities. Similarly, nursing staff often feel that the emphasis of nursing care is directed towards the ‘management of dangerous behaviours and patient throughput’ (Lelliot & Quirk, 2004, p. 300). They are also dissatisfied about the lack of time to engage with service users beyond the immediate pressures that present themselves. Duffy and Nolan (2005) and Simpson et al. (2005) reported that occupational therapists working in acute hospital environments were discouraged by the multi-disciplinary teams’ misunderstanding of their role. These frustrations may have contributed to an ‘exodus’ of staff from acute wards to new community teams, such as assertive outreach and crisis teams, as reported by Dennis-Jones (2005).

Transition to crisis intervention

For occupational therapists, the move away from traditional hospital departments to community outreach and in-reach programmes and other new ways of working such as in crisis resolution teams is challenging. Gage (1995) in Canada and Lloyd et al. (1999) in Australia found that occupational therapists faced similar issues when ways of working changed. These changes are often perceived as a threat. There appears to be two areas of concern: the move away from working within an occupational therapy team and having to use additional skills in conjunction with core expertise.

Perhaps, there is an inherent safety net in working within a team of occupational therapists in an in-patient unit where there is a readily available pool of colleagues who can offer informal support and understand the struggles that the practitioner faces. However, the frustration of working in the hospital is that environmental factors affect the occupational therapist’s ability to carry out intervention. For example, lack of physical space and resources, the diverse needs of service users admitted to in-patient units, unpredictable ward environments and policy and procedures restrict the ability to carry out interventions. The frustrations of inpatient work can affect both the occupational therapists’ satisfaction with their work with service users and the service users’ experience of occupational therapy during admission.

Conversely, working in crisis resolution can offer the occupational therapist the opportunity to work with service users in their own environment, using the service users’ own resources such as familiar objects and people. However, each crisis team is likely to have only one occupational therapist; so support from other occupational therapy colleagues can be limited. Finding allies in a team who will provide support is invaluable. But regular professional supervision by an occupational therapist allows practitioners to retain their occupational therapy focus while reflecting on their experience of working in different ways that incorporate some generic team tasks. This supervision is also an important aspect of continuing professional development.