Who should come out when we dial 999 for mental health? MHT meets Dr Lucy Johnstone

Mental Health Today interviewed the figurehead of the 'Drop The Disorder' movement when the touring event rolled into Brighton recently. Providing psychological support and co-producing a picture of ‘what happened’, rather than ‘what’s wrong with you’, underpins their approach to mental health care generally. It resonates with many.

We wanted to hear more about how responding to mental health needs in a non-medical way – which is not in itself a wholly new idea, of course – might look when people are at their lowest point and they or their loved ones are faced with needing hospital support.

Mental Health Today: Do you think society is right to consider 999 as the default option to turn to in the context of suicidal thoughts?

Dr Lucy Johnstone: In the present circumstances, you have to use what’s available. People sometimes say ‘the crisis team wasn’t helpful’ and yet there’s nothing else but the crisis team. Or they say ‘I rang 999 and all it did was I got dumped in A & E again’. But if there’s no alternative then that’s unfortunately what people have to do (at the moment).

• Editor’s note: To be clear – neither Mental Health Today nor Dr Johnstone wish to discourage anyone from calling 999 if they or someone they know needs urgent support. This is an interview exploring different ways services could be structured in the future.

I think there will always be (a need) for something urgent. The crucial thing is what happens when you need it: who you phone and how they approach it. It could certainly be done very differently and a lot better. A 999 service could, like anything else, be trauma-informed. So it wouldn’t be about saying ‘you’ve had a crisis, go to your GP, get more pills,’ it would be about understanding that there’s probably been some trigger, that it probably relates to other things that have happened to you, that you need to be kept calm and safe, and using lots of non-medical ways to keep someone calm and safe. It would be nice to find that on the end of a 999 call, even if admission or whatever was still necessary.

"Crisis houses do exist, but hardly. They’ve got the right approach and it often boils down to simple, ordinary human contact."

Mental Health Today: We are used to seeing a certain type of signposting from websites or individuals: if you’re in distress go to your GP, arrange a diagnosis, or call 999. Do you believe this should change?

Dr Lucy Johnstone: It’s tricky. I’d like to see charities be much more honest about the limitations of what you’re likely to find [through following their signposts]. It feels like the message often is ‘see your GP, you’ll be fine; call 999, you’ll be fine’. You may not be. There are very serious limitations to those services and I would like to see charities campaigning much more actively for a trauma-informed approach to distress. That’s not what national charities such as Mind are necessarily promoting, although local branches of Mind are often very supportive of that kind of approach.

• Mental health professionals and members of the public are invited to discuss and hear expert discussion on alternatives to A&E at Mental Health Today Wales on May 10.

Essentially there is a risk that charities end up propping up the system as it is and I think that’s not what charities should be doing. They should be challenging systems more openly. For example, there’s a charity called Young Minds that I came across recently that have produced some really excellent trauma-informed resources for working with children and young people as opposed to simply promoting and disseminating the diagnostic model of distress, as national charities like MIND and Rethink too often do.

Signposting doesn’t have to be like it usually is. Charities should be championing a different approach, I think. It would be much better to signpost people to website or other resources, even if services don’t [always] exist. At least there would be other ways of understanding your distress [alternatives to disorder diagnosis], which is [an approach] most people are never introduced to.

• See also: 'A disorder for everyone'

Mental Health Today: In some parts of the country, there are nurses in 999 control rooms, who will go out with police when a 999 call is considered a ‘mental health call’. Do you believe that should be more widespread?

Dr Lucy Johnstone: I’ve come across that kind of approach. Obviously it depends on the team and the person, but in general I’m not convinced it will help a great deal as long as they are going out with a medical hat on, or if they’re going out not to offer support themselves, but to do this thing called ‘signposting’, that we’ve discussed.

Signposting can sometimes be shorthand for ‘not actually getting involved myself’. It’s very easy to signpost – yes this looks like a manic episode, go to A&E, go to see your GP, go to see your crisis team. I think the role of nurses, and other professionals, in mental health does need to be very different.

Mental Health Today: Should there be a role for psychotherapists in 999 control rooms?  

Dr Johnstone: I hope so – psychotherapists (and also) support workers, therapists, housing workers and debt advisors. There are lots of people who could be useful in a crisis but the medically trained professionals are often not the people who are most helpful in a crisis.

Mental Health Today: How would it work – would therapists and the other professions you’ve mentioned come out and stay with people for an hour, or overnight, or…?

Dr Lucy Johnstone: Ideally they would. There’s a service in Leeds, called the Leeds Survivor-Led Crisis Service, for women, which there’s quite a lot about online. They work in a completely non-medical way and a very flexible way. They are there for emergency calls. They are trained to offer listening and non-judgemental support.

It’s not fancy stuff. It’s about being with someone, listening to them, supporting them, helping to keep them safe, showing they’re on their side, giving them encouragement, giving them a bed for the night if they need it in a non-clinical setting… a nicely-appointed house, where there’s a people to sit up with you all night if you need it.

They’ve been enormously successful. They’ve never had a suicide as far as I’m aware. Certainly they’ve had much better outcome rates than normal services. So it is possible to do those things. If that was replicated nationally it would be fantastic. Things like crisis houses do exist, but hardly. They’ve got the right approach and it often boils down to simple, ordinary human contact really.

Mental Health Today: Jeremy Hunt, the health and social care minister, recently attracted a mixed reaction by setting the NHS a ‘zero suicides’ target. Elsewhere, the Zero Suicides Alliance believe it’s possible to reach this, not just within NHS services, but across society…

Dr Johnstone: There’s never going to be ‘no suicides’. Zero targets are unattainable. It’s a really unhelpful thing (for Jeremy Hunt) to say. How are we supposed to respond to that? So, we can only fail then? It’s adding another pressure. ‘Oh no, this person might kill themselves.’ It creates pressure to admit people who might otherwise not be admitted.

One of the groups most at risk of suicide is middle-aged working class men who lose their jobs. So what’s that about? Well it’s about lots of things but it’s about unemployment, it’s about men who’ve been encouraged to put their whole lives into certain forms of identity, it’s about men being socialised not to talk about their feelings, it’s about men being cast on a scrapheap with no counselling support. You can’t just look at the other end and say we must stop them killing themselves - it’s just not the right way to proceed. We need to address the underlying causes - individually and as a society.

Dr Lucy Johnstone will be talking at Mental Health Today Wales in Cardiff on 10 May. Buy tickets here.