Mental Health Triage is our Crisis service in SA, and whilst they have an incredibly important job, they can at times be difficult to interact with. Sometimes this is just determined by who you get on the other end of the phone and how bad a night they’ve had so far. I’ve had to call them as a carer or friend on a great many occasions, and I’ve learned a few strategies that seem to make things a bit easier for me. Your mileage may vary, but here’s my tips:

1. Have a clear goal in mind
Before you start the call, work out why you are calling them. I know this can be difficult when things are in crisis, but if you don’t know what you want, you’re not all that likely to get it. Are you updating them with important information? Do you need them to speak to the person you’re worried about? Are you hoping for a visit from their staff? Do you think the person urgently needs hospital? Do you need police support? Work this out before picking up the phone if you can.

2. Gather the person’s information
I can never remember everything I was going to say once I’m on the phone. Write down a list, and tick them off as you go. Having everything in the one spot means less fuss running to check the name of the current treating doctor, or what dosage of medications they’re on this week. The more chaos and change in the person’s life, the more important it is you take a few moments to check all your information. You may need to know the person’s

• current diagnosis
• medications
• treating doctors/therapists
• hospital ID numbers
• full name
• address
• date of birth
• phone number
• dates of important events (eg. she was last in hospital on…, he stopped taking his medication on…)

You can still call if you don’t have these – eg. you’ve just stepped in to help a stranger in crisis on the train – but if you can put this information together first it will help smooth things.

3. Lay out the situation really clearly and simply
Mental Health Triage get millions of phone calls from desperate, incoherent, stressed out people. Assume for a moment they have no files whatsoever on your person, even if they do or should have. Give them the dot-point version (that you’ve already written down) of what’s going on and explain very, very clearly why you are concerned. For example:

I’m calling on behalf of my friend Lauren. She has schizophrenia and becomes suicidal when she is unwell. I’ve just discovered she stopped taking her antipsychotics on Tuesday, she’s not eaten in several days. She’s just phoned me very upset because she thinks her neighbours are trying to kill her. She is barricading her apartment.  I’m concerned that she is a danger to herself and unable to care for herself at the moment. Can you please speak with her or send someone to her apartment.

Don’t assume anything. Don’t assume that it’s obvious you would want the police to come, or that the person clearly needs hospital. Don’t assume that saying something like “He’s becoming very withdrawn and won’t speak to me” will ring the kind of alarm bells for them that it does for you. You need to tell them that the last time he did that, x happened. Tell them what you need and explain why.

4. Cry some place else
That sounds pretty harsh, but I’ve found that if I keep really clear in my mind that Mental Health Triage are a crisis response service, not a counselling one, I have an easier time in conversations with them. Very occasionally a lovely person will look out for you and let you talk for a moment about how you’re feeling and coping. But going in, I assume that they are not there to meet my emotional needs. I am as calm, clear, and professional as possible.

This doesn’t mean your emotional needs aren’t important! On the contrary they are extremely important and it’s best to take them to safer places they are more likely to get met. If you need to follow or precede a call to Mental Health Triage with one to Lifeline, a good friend, your Mum, whoever, then do it. But in all crises, there’s a time to cry and shake and feel things, and a time to call the police and clearly tell them your address – or whatever. Don’t get them mixed up if you can.

5. Recruit help
Sometimes in a developing crisis you have your hands so full with the person you don’t have the energy or time to make phone calls as well. If a couple of you can work as a team that can take a lot of the pressure off. I’ve done this quite a bit, someone sits with and calms down the person, someone else makes the important calls. Doing it all yourself is a recipe for burnout.

Also use this technique if for some reason Crisis Services aren’t taking you seriously. I’m sorry to say that as the carer/family/friend your experience and opinion often count for very little. If you are looking out for someone with high risk issues such as a person with Borderline Personality Disorder, there will be times when you really struggle to get the help that’s needed. Persistence is the key. Keep calling them, and get everyone else who’s worried to call them too. There are resources and supports out there, but unfortunately they tend to go to the squeaky wheels. Don’t suffer in silence, squeak as loud as you can. There’s a lot of decisions made that are more about personality than anything else – sometimes one staff member will block all access but if you call back in 6 hours the next will be on board. Sometimes you only get the service your person needs because they are fed up with dealing with the calls, and while that is awful it’s better than nothing.

6. Do without them wherever you can
Especially if your person if in chronic distress, try not to escalate a situation by jumping for Mental Health Triage every time they wobble. Look at the patterns – eg issues with medications etc. and expect more of the same. Try to take as much of it in your stride as you can. There isn’t a magic fix for these kinds of issues. As much as we told to ‘ask for help’, there is no quick way to take away emotional pain. A lot of the help and healing your person needs is probably not going to be found in the crisis services. They can hospitalise or medicate, but that’s about it really. Sometimes that’s life saving, and sometimes it’s just more running around only to have them back home in the same mess in a week, or two days, or 6 hours. It’s not always worth it.

Concentrate your energy whenever you can on the other supports – finding a good doctor, a therapist, social support, maintaining stable housing etc. Be aware of the limitations of crisis services and don’t get hooked on the idea they can offer a solution that they can’t.

7. Give them feedback when you can
Crisis services can be frankly a horrible place to work. Any kind of front-line work like this has a lot of people having the worst days of their lives, feeling totally overwhelmed and miserable. If you have a positive experience, be sure to let that person or the service know that what they’ve done has made a difference. Treat them with respect and dignity. We need to look after the good folks in these kinds of roles so they stay around and look after the next person. On the flipside, if you have a terrible experience and have the time/energy, make a complaint. Be clear about what you wanted and what you didn’t like. It won’t change the world, but it can be part of culture changes.

8. Maintain credibility
As a friend, family member, or carer, you may be quite surprised to find how little your opinion counts. This holds true in my experience, even if you have extensive experience and qualifications in mental health. That can be a shock. If Mental Health Triage or any other service decides that you are overly anxious/unreliable it will be next to impossible to get them to take you seriously. The heart-wrenching thing is that there is basically no accountability in mental health. If your person kills themselves after you spent days arguing they should be in hospital, it is extremely unlikely anyone will be held to account for it. Additionally, we are in a no-win situation where suicide is often considered to be proof the person was beyond assistance anyway. This means you are far more invested in the outcome then nearly anyone else you will speak to – often including the person you’re worried about.

It’s not unusual to find that one minute you are told your person is not unwell enough to be offered a service and the next to be told they are too unwell. You may also discover processes that make your person much more unwell and distressed such as turning them away from services and telling them “until they actually self harm (instead of thinking about it), or have active suicidal ideation (instead of ‘passive’ thoughts) they can’t receive help”. Many people in distress start self harming or planning suicide due to situations like this. Many also become aware that the services are actually harming them and refuse to engage anymore, even with the good useful ones. It’s a crazy-making process and there’s nothing wrong with you if this stresses you out terribly too – but be careful of letting them see the impact on you. It’s a normal response to cry and yell but in mental health and crisis services will be seen as a sign of you ‘not coping’ and being mentally unwell, and therefore unreliable as a reporter of whatever is going on.

You need to do whatever you can to retain what little credibility you have. That means working with the system and accepting it as it is, instead of being fooled by the packaging into thinking it’s going to adapt to you. The more you can mimic their behaviour and speak their language – detached, professional, calm, courteous – the better chance you have of being taken seriously. As much as you can, make them like you and want to help you. Don’t let them write you off as emotionally unbalanced when the stakes are this high.

9. Ignore useless advice
As a carer/friend/whatever, you will get a lot of contradictory, useless and unhelpful advice. The crisis services are really good at this in my experience. Boiled down most of the bad kind turns out to actually be something like this: “If you were less involved, no one would be ringing me about this difficult person and my job would be easier”.

I’ve had the bizarre experience of being told off by one staff member for being over-involved and not involved enough in someone’s care within the same conversation. If it can be made to be your fault somehow you will probably hear about it at some point. A lot of people who know nothing about you or your caree will tell you how to care for them and let you know they think you’re doing a pretty lousy job.

Others will laud you and invite you to collude with them in how awful the person you care about is, or offload their frustration or distress onto you. Not your job.

I’ve also had experiences of emotional blackmail from crisis services, including Mental Health Triage, for example being told “But what if someone else dies tonight because your (person) was in the last hospital bed?” Some people find it difficult to work in a service and acknowledge its limitations. When things fall apart that means it will turn out to be the person’s fault, or your fault. Expect this and learn to tune it out as much as possible when picking them up on it would only distract from your goal. Find somewhere safe to rage or cry about it later. Don’t take it on board or let people undermine you.

10. Maintain value

There’s often a conflict between your perception of the person’s value and that of the services. People do get written off in many different ways, “it’s just behavioural”, “they’re doing it for attention”, “he’s a hopeless case”. Most services are kindest to people in the first instance of crisis, in short term crisis, and to people who are from the most culturally valued backgrounds. If your person is marginalised in some way, and/or has been in crisis for awhile or more than once, then they are risk of being devalued. As this happens the services may refuse to engage them at all, and/or the ‘care’ they receive may actually be thinly veiled contempt. Some services have endemic problems with treating all people with mental health crises this way, for example both police and ambulance services have many wonderful compassionate individuals, but also many who are cruel and use abuse and neglect to harm people. Sometimes this is a lack of understanding/training/empathy. Sometime it is simply a form of victim blaming where limited resources and too many people in need are blamed on those perceived as undeserving/not really in need. Victim blaming is endemic in our culture around mental health and the crisis services are not immune. 

You may see issues such as stitching self harm wounds without anesthetic, cruel responses to distress such as isolation rooms and inappropriately high dose sedatives, needlessly rough handling, leaving people in wet/soiled clothes, deliberately choosing procedures the person finds frightening, not allocating a bed, losing personal belongings, and traumatic conversations. You may not even be aware many of these things are happening as people in crisis often find it difficult to communicate. There are many subtle ways someone can be punished if they have been perceived as ‘wasting precious health resources’.

Be sensitive to subtle signs your person is being devalued and fight back by humanising them. Dress them in good or formal clothes. Do their hair. Show photographs of their family or children. Find small ways to remind people of their job title or degrees or educational plans. Bring flowers when you visit, even if this is their 100th hospitalisation. If you can, complain about or directly confront any abuse or neglect you witness. (once in an ER I overheard staff laughing about my person while I used the public toilet) Emphasise their dignity. Make sure staff are aware you see this person as valued and you are plugged in. Having even one member of staff see your person as valued and not to blame for their suffering will help protect them.

11. Don’t let the system burn you out

If the circumstances are desperate, use every bit of leverage you have to get care. Once I was homeless along with the person I was caring for. They were in life threatening crisis and I had no resources to support them. Mental Health Triage were flatly refusing to offer any services and running us around by sending us to hospitals then losing the referrals and the case notes, forgetting we were waiting for a consult, and so on. When I complained about the situation I learned the team had assumed I had a “home with a husband and white picket fence and was just offloading family I didn’t want to care for onto the over stretched mental health system”. No one actually asked me, and these assumptions were putting us at great risk.

Once I managed to get someone in crisis admitted to hospital only by threatening to kill myself. (the logic of admitting someone to hospital on the basis of someone else talking about suicide is mind bending) Another time someone had spent over 12 hours in Emergency with open wounds, untreated and without food, water, or a bed. They finally stitched her up when I threatened to contact the local newspaper health reporter. Another time I refused to allow someone home so the hospital would be forced to admit them.

These are not things to consider lightly and they may cost you all the credibility you have built up. But while there is a lot of lip service to the idea that your needs count too, it is not uncommon for carers to pick up the tab for overtaxed services. Sometimes this is the best thing you can do – bring in meals they actually eat, make sure someone gives them a nicotine patch within the first 48 hours, correct the wrong med they are being given. But also, you mustn’t let them lean on you when it’s killing you both. It is not the person in distress’ fault the services are broken. Nor is it yours.

12. Be careful – Manage their anxiety

Sometimes the best crisis care is sitting in the backyard and throwing ice cubes at the fence, screaming in the car with the windows wound up, or 9 hour baths. For some people and in some places, crisis services can be not just traumatic but lethal. Police do kill people in crisis. You may be very low risk and find that hard to process, but it means think twice about how you navigate and advise in crisis especially someone else who is at high risk. 

Competent crisis intervention recognises that crisis is vulnerable, volatile, and sometimes beneficial. It is about connecting, validating, empathising, and de-escalating. It is profoundly human. If you want to watch competent fictional crisis intervention, checkout the series Flashpoint. This exists in our crisis services but it’s not across the board by any means, and is largely a result of informal people skills. Meaning that those who were already good at this make great paramedics, social workers, etc. And those who were already awful are rarely improved through their formal qualifications.

It’s hard to get inside the head of someone who makes things worse in a crisis or hurts someone already in so much pain. Sometimes you can understand the different perspectives better when you apply your own empathy – a nurse sick of being attacked is obviously going to be more focused on neutralising threat than emotionally connecting. A police officer who believes someone in psychosis is sick and needs treatment won’t stop to think about the process and if it’s trauma informed – getting that person into hospital quickly is their job, and it’s the person’s job to comply (in their mind). Sometimes crisis services are best not called, or called only when you have the capacity to influence, calm, and de-escalate them, too. 

***

Most of that isn’t fair at all. You’re already working hard to support the person, probably exhausted and scared out of your mind, and feeling all the intense feelings that crisis generates. Services like Mental Health Triage should get that and accommodate you and your needs too. I couldn’t agree more – and occasionally it may happen that way. But that’s not been the norm in my experience. Take good care of yourself, it’s phenomenally exhausting supporting someone in crisis.

If it all goes belly-up and you can’t follow a single one of these tips but you need them, call Mental Health Triage anyway.

If your person is dealing with anything longer term such as dissociation, multiplicity, an eating disorder, borderline personality disorder, PTSD or psychosis, you may not get any useful support from Mental Health Triage at all I’m sorry to say. The level of discrimination against dissociative and multiplicity conditions is extreme and many crisis staff consider them all faked for attention. Most crisis services won’t respond to eating disorders unless the person is in acute medical crisis and even then there’s a lack of training about what to be aware of. You may have some intense advocating to do and sometimes have to fit the services to your own approaches, such as using the ER to re-enforce that someone with an eating disorder must eat at home or they will be taken to hospital. The hospital may not be happy about their role in this process but they don’t have to be.

Your best route is to stay out of crisis as much as possible, and get good support staff on board. Finding ways to manage crisis without needing services can also protect you both. You may need to get private hospital cover and look for a psychiatrist with admitting rights instead of risking the public system.

It’s also important to be aware that the highest risk time for issues like suicide is often just after the sense of crisis has eased. Discharge from hospital for example, is a common time people are highly vulnerable, traumatised, and feeling very alone and exhausted. While this has been widely recognised for a long time, in most settings little has been done to address it. Sometimes not being able to access services is a twisted blessing in disguise.

Good luck, take care, and get some support.

Mental Health Triage in SA: 13 14 65
Lifeline: 13 11 14