Psychiatric Liaison – adding insult to injury?

According to the Royal College of Psychiatrists, “Liaison Psychiatry is the sub-speciality which provides psychiatric treatment to patients attending general hospitals, whether they attend outpatient clinics, accident and emergency departments or are admitted to inpatient wards. Therefore, it deals with the interface between physical and psychological health.” There is a ‘Faculty’ for Liaison Psychiatry at the RCPsych and they are running a pilot to develop a credential in Liaison Psychiatry.

The academic and training view of RCPsych is a world apart from my experiences of Psychiatric Liaison in my local Accident and Emergency, (A&E) department. I am emerging from a mental health crisis which involved at least 12 visits to A&E and minor injury units within the space of just several months. I self-harm by cutting my body as a last resort during times of extreme distress. The self-harm is not ‘addictive’ in nature but it is incredibly painful. I harm for the need to get this act over with in order to have a chance to feel better later. I feel compelled to cut and displace the distress, thereby enacting deep inner pain which is beyond words. In the past I have needed surgeries, multiple blood transfusions and countless stitches. Attendances at A&E have been only the tip of the iceberg of my self-harm and it has been far more usual that I go to see the nurses for wound sterristripping at my GP practice or self-treat.

If Psychiatric Liaison does bridge the interface between physical and psychological health then I may seem an ideal candidate for its expertise. My self-harm does have physical complications, not least iron deficiency anaemia and open wounds that take time to heal. I welcome advice, practise harm minimisation and am crying out in pain during a cycle of self-harm. Recently when cutting one area of my body I hit major veins and the blood loss necessitated ambulance call outs. After the second ambulance I decided to avoid harming this area of my body as I don’t want to bleed to death. I am resolved to reduce the harm and minimise my ‘impact’ on local overstretched health services.

I must report that my experiences with Liaison Psychiatry have added insult to injury. A ‘good’ visit to A&E involves not only physical treatment with adequate anaesthesia, but the treating medical doctor agreeing that I don’t need to be referred to the Liaison or Crisis Team, (the Team which is on call depends on the time of day or night). I explain that I have seen the Crisis Team and Psychiatric Liaison in the past and they have nothing to offer. I usually wait hours in the department for the Liaison Team to come on duty or finish with other patients then they permit me a ten minute chat. This chat usually consists of asking why I am there, was the self-harm superficial, (would I be there if that was the case I wonder?), have I tried counselling and how will I get home?

The Liaison practitioner may feel the need to draw up an action plan which will say something like ‘aware of crisis numbers.’ Since the crisis numbers such as the Samaritans and the local mental health helpline are widely available I don’t need to be given them. I don’t see why I should have waited hours on top of the prior three hours wait for physical treatment for this unnecessary assessment which will just tick a box for the service.

My resistance to Psychiatric Liaison probably relates to the fact that they work for a mental health trust which discharged me in 2015 by saying they would not see me again while I had the ‘same presentation.’ Since I have no history of psychosis I am not sure how I can morph into a different presentation which would be more agreeable to the mental health team. Over 16 years ago I was given a diagnosis of Borderline Personality Disorder and this still follows me around even though no-one ever reviews it. Previous GPs have made referrals to the ‘Access Team’ which get batted back with conversations with the GP along the lines that I should ‘take responsibility’. I have worked full-time for the last seven years and pay to see a private psychologist.

I don’t know what else I can do to prove I am ‘taking responsibility’ except perhaps drop off the radar of all health services. Sometimes my death would seem like a better outcome to mental health services than my attempting to ask for help that doesn’t exist. I know that Psychiatric Liaison presents a dead end since they have no services to refer into which wouldn’t be hostile to that referral. My local mental health trust is taking part in the ‘Open Dialogue’ pilot but this approach, which comes with much praise for its innovation, would never be open to someone in my type of crisis.

My recent experiences of Psychiatric Liaison have confirmed my misgivings about this service area. I was referred to Psychiatric Liaison by a very thorough medical doctor in June. The doctor spent over an hour suturing wounds. He even said that he didn’t like to see those kind of wounds on anyone and believed that I deserved help and that services had changed, with new options available, since they had discharged me several years ago. He asked if I was under a psychiatrist and I said that I hadn’t seen one since 2013 and services would have no desire to help again.

But in the spirit of being a co-operative patient, and truly being grateful that he did bother, I went along with the referral. The problem was that it was 11.30 pm on a Saturday once the physical treatment was over. The doctor escorted me to the Clinical Decision Unit in the hospital to wait for the mental health team. I then endured a nine and a half hour wait sitting in a chair for psychiatric ‘assessment’.

I would expect the Crisis Team to cover at night where Liaison are commissioned to operate from 8 am – 8 pm. However, it seemed like the Crisis Team didn’t want to come to the hospital that evening and I had to wait for Psychiatric Liaison to arrive on shift on the Sunday. I was seen at 9.15 am by an Occupational Therapist and another quieter unknown team member who chatted to me for ten minutes. I explained I was very distressed and needed to get home. I am a key contact for an elderly parent who would wonder where I was since I hadn’t phoned her that day. The OT still insisted on ticking boxes by talking and drawing up an action plan. I signed the action plan rather than waiting for another ten minutes she said it would take for her to write out this plan.

I was never sent a copy of the plan and have no idea what I signed. I imagine that the plan may have said that I had the crisis numbers and was to go back to work. There was no apology for the nine and a half hour wait in the chair or understanding of the distress and total lack of sleep this had caused. I had tried to self-discharge during the night but had been told by medical staff that the A&E doctor had been worried enough about me to call the police if I left the hospital. Since I have no wish to waste police resources I figured I would need to stay no matter how uncomfortable.

On my next two A&E visits I did see a consultant psychiatrist which seemed unusual given the community mental health team operates with locum psychiatrists and has had no consultant for many years. I was initially impressed by the consultant who had read notes I made in 2015 saying I didn’t want to see Liaison due to the long waiting time which led nowhere. My second meeting with him was less thoughtful due to his assumptions. A friend had accompanied me to A&E and the psychiatrist seemed more interested in talking to her about what she felt was behind my behaviour rather than asking for my account. The psychiatrist said that they didn’t want to make it ‘too comfortable’ for me to attend A&E or they were ‘enabling’ me. I tried to explain how I didn’t enjoy attending A&E and was going for clinical reasons, ie a wound that needed closure through stitches and not because I was a bit upset.

My friend did voice that she thought I needed help from services. The psychiatrist, who was meeting me for only the second time, said that the community mental health team couldn’t help someone like me as they only saw people with a chemical imbalance and were better when there was a clear goal like a medication review or getting someone into voluntary work. The psychiatrist said he didn’t think I was someone who needed to be on medication. He also decided that he would have a professionals meeting to come up with a ‘plan.’ He intended to contact my GP and a primary care nurse who I met only twice two years ago. My private psychologist knows me extremely well but he didn’t contact her at any stage though I supplied her mobile number and email address.
The psychiatrist then said that I wouldn’t see him again even if I went to A&E and he wasn’t my therapist. I asked the psychiatrist for sleeping tablets but despite being based in an A&E department he wasn’t able to prescribe any! He instead faxed a plan to my GP suggesting he ‘considered’ a 14 day course of zopiclone at the lowest possible dose. I tried to explain that I have no history of dependency on medication yet still it felt as though I was asking for hard drugs. Thankfully my GP prescribed sleeping tablets and a tranquiliser without questioning my motivation. I use this crisis medication very sparingly.

The psychiatrist also told me that I should go back to work, this was despite my being physically depleted at a level where other patients may be transfused and at risk of my problems spilling out to colleagues in my distress. I only took one week off work but again it was as though no-one except my GP and psychologist recognised the need for me to do this and spend time with supportive friends. The psychiatrist discharged me to a crisis café which is operated by a voluntary sector organisation and only open for two evenings a week. The crisis café does not offer emergency appointments but feels to me like an extension of their day services which have been reduced by funding cuts.

Since these encounters in A&E I have gone instead to a distant Minor Injury Unit for treatment where I won’t have to see Psychiatric Liaison. These units are nurse led and can perform stitches. However, since stitches take a long time the two nurses on duty will use stapling instead. The staff advise that local anaesthetic isn’t needed with staples but I have felt immense pain when wounds were washed then stapled without any pain relief or anaesthesia beforehand. I feel that Liaison is being used as a deterrent to keep people like me out of A&E yet the consequence is that we will instead have to find other urgent care settings willing to treat us.

When I visited the crisis café one of the paid workers said that a member of the Psychiatric Liaison team had visited the café to say that they are focusing on trying to reduce the number of A&E attendances for mental health reasons as there are too many when A&E is under pressure. My view is that a crisis café which is open for eight hours a week isn’t going to offer a real alternative to A&E and statutory services for someone in acute crisis involving active self-harm or suicidal feelings.

One of the alternatives I used during this crisis was a London A&E department. This experience was a more extreme example of Liaison being used as a deterrent. On being referred after stitches by the doctor to Liaison I was taken to a separate area of the hospital where there were bare rooms with security guards outside them. I was searched and patted down, including my breasts being touched without my consent, by a member of staff who confiscated my bag containing all belongings such as my keys and mobile phone. I was then given a blanket and told to lie down while waiting for someone to see me. I hadn’t eaten, drank or been to the toilet in six hours and I felt terrified. It felt as though I was being detained like a suspect in police custody.

The Liaison nurse did see me after 30 minutes and was extremely apologetic during our ten minute chat. She said that all A&E departments in London were like this as it was their ‘protocol.’ She recognised that I wouldn’t go to this hospital ever again. I needed to use friends and my psychologist to deal with a traumatic stress reaction I experienced within the next few days. I blamed myself for ending up in this A&E and having this reaction, even though it was a London walk-in centre that had sent me there as they couldn’t perform the stitches I needed.

Psychiatric Liaison as a service development needs to be clear about its practices including not using de facto detention in hospitals, such as threatening to call the police or positioning security guards outside bare rooms. This type of detention is illegal without formal sectioning. The assessment should be voluntary and advocacy services are really needed. I see no benefit of Liaison services to people who recurrently self-harm and cannot access help in the community other than by paying for this. However, I can see that Liaison may be able to signpost those with drug or alcohol addictions to treatment or to assess an elderly confused patient for dementia.

I did have one helpful experience in 2015, and I wrote to the Trust to give a compliment, where I was on a ward for surgical debridement and closure and the psychiatrist had visited me on the ward then liaised with the surgical team about my needs. The psychiatrist had been encouraging about the progress made over the years and of the view that secondary care services should offer support. While commissioners are investing money in Liaison there should be clear outcome measures and user involvement in the approaches offered. There should be brief interventions not just a one off chat amounting to ‘how will you get home?’.

The Deliberate Self-harm Team, which was eliminated at the local hospital when Psychiatric Liaison came into being, did offer problem solving meetings and handed out a first aid kit for self-harm which ensured clean blades were used and thick sterristrips were tried at home. This dissolved team did at least have a clear purpose and understanding of those attending who do external self-harm.

I would suggest that Frequent Service User Managers for A&E also offer a more meaningful service. Fortunately, I do have a care-coordinator through a high intensity service user project funded by the CCG. The role of this specialist nurse is to meet people whose attendances have hit a certain threshold and to understand the root causes of their presentations to A&E. She takes a holistic view and understands that crises can be triggered by many social factors such as benefit sanctions, financial, housing and work problems. This nurse has given me a mobile number and suggests I call before things escalate. She has accompanied me to meetings with the HR manager at work given the recent crisis was triggered by my job.

She has also visited the police station when a neighbour’s antisocial behaviour put me on edge. She is not at all punitive, shaming or deterring me going to A&E and recognises that until recently I hadn’t attended for over 16 months. Instead she recognises that the A&E visit is necessary and I know myself best, but to suggest other options which may also help before reaching that desperate point. With her input, I have developed a care plan for my self-harm for the GP practice which indicates my choice of dressings and the nurses’ need to understand that I am in pain with injuries.

I am very grateful that this specialist nurse was also able to ask Psychiatric Liaison not to arrange a professionals meeting and for a note to go on my A&E records asking that I am not to be referred to the Liaison team unless I request it. I don’t think this note on my records is ideal given I am in huge distress when I do go to A&E, but it is a means of saving me further distress in being exposed to psychiatric assessment for no purpose. Harm minimisation can apply to steering clear of pointless ‘interventions’ as much as it can to avoiding life and limb threatening injuries.

There is a risk of referral to Psychiatric Liaison raising hopes of help available to those who self-harm or are suicidal. I guess I have reached the point of knowing this help doesn’t happen so hope is futile. This is another reason why referral should be considered and not automatic as it is a false expectation of help. A ‘plan’ won’t pay for my psychology sessions as I find myself having to apply again for Personal Independence Payment.

A ‘plan’ doesn’t provide a support service instead it is another message that this is ‘all down to you’. I have found the medical staff far more compassionate and helpful than Psychiatric Liaison so I don’t see that the Liaison staff have a training role to do in the department.

I am always apologetic to medical staff in A&E and ashamed of my presence there yet the medical staff are usually saying that I should attend if I have a wound that needs proper closure. The timing of the psychiatric assessment, after long waits for physical treatment, is also misplaced given tiredness and pain may make going home the best option.

I hope that there can be debate rather than gratitude for Psychiatric Liaison as its rolled out to all general hospitals. Psychiatric Liaison in its current form could just be adding to the pain.

Rita Binns

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