Monthly Archives: July 2014

Our mystery mental health worker has written about taking a referral from the Early Intervention Team

We welcomed the Early Intervention in Psychosis (EIP) service when it was set up and some of our workers moved on to take posts in the team. It was uncomfortable however when they became the new exiting team with lots of attention from management while we got our budget cut. So more recently, I was not very supportive when they started referring their service users to our team. Why, I asked, would we offer more of the same, when this had not worked? Three years of intensive outreach interventions had not delivered outcomes and now they were asking for more of this!

I am not just being awkward, this is a reasonable question. With cuts to our resources what should we do when people do not turn up to appointments? A young man, Ashleigh, had engaged well with EIP, at times. But then he failed to take treatment and he was difficult to trace in the community. The EIP workers managed to get him to the local Housing Department a couple of times but he did not stay in the temporary bed and breakfast accommodation he was offered. Ashleigh is a ‘sofa surfer,’ staying with various friends for a few days then moving on. He also stays with his mother, but when he comes back late after drinking alcohol or smoking cannabis with his friends she does not let him in. He explains that he often sleeps in the garden shed. When you can find him, Ashleigh presents as friendly and motivated. He promises to settle down and to find work, but when arrangements are made to attend appointments or organise activities, he cannot be found.

Ashleigh’s friends are aware that he has mental health problems, but they do not treat this with any seriousness. It seems that it is great fun to wind Ashleigh up and get him into trouble. He now has a criminal record for minor offences, criminal damage, affray, breach of the peace etc. Across his time with EIP, he was often admitted to our acute psychiatric hospital, responding to voices, feeling paranoid and entertaining ideas about persecution. Last year he absconded on a number of occasions and was then discharged in his absence. He recently appealed against his detention under Section 2 and I travelled to the local PICU to present the Social Circumstances Report. Ashleigh had the support of a solicitor and a mental health advocate. He successfully minimised all concerns about his non-engagement and non-compliance with treatment. He said he would take treatment this time and explained that he just wanted to get a job and get on with his life.

The hearing was going well for Ashleigh. He was again presenting as capable and able to take control of his life. However the doctor stuck with the evidence and described symptoms such as a fear of being watched or followed. Ashleigh was described as making threats against someone he met in the street. He thought this man was recording his actions and when this was mentioned at the hearing Ashleigh started to show signs of anxiety. He challenged the doctor repeatedly; asking why was he so unsupportive? The panel agreed to take a break and I listened to the mental health advocate talk with Ashleigh about the need to emphasis recovery philosophy, rather then pushing the ‘medical model.’ Then, back in the hearing Ashleigh lost his self composure. He told the doctor he would get him struck off, accusing him of being involved in a vendetta against him. Ashleigh was sent back to the ward and the Section was upheld. However, a week later Ashleigh was made informal and transferred back to our local acute ward. The next day he climbed over the roof and has not been seen since.

Our team has taken the referral but Ashleigh’s new care co-ordinator has not met him, despite every effort to make contact. I we spoke with colleagues in EIP who believe Ashleigh is developing an entrenched mental health problem, causing problems with his concentration and his ability to remember things or organise his affairs. In contrast, it seems that he thinks there is nothing wrong with him. If he does feel anxious he believes that a can of beer or some cannabis are better solutions than taking anti-psychotic medication. But our colleagues in the Recovery Team would have to discharge Ashleigh due to his failure to attend appointments. In Assertive Outreach we are concerned by his ‘life-style choices.’ We do not see these as separate from an underlying psychotic illness. We will keep trying to engage him in the hope that we can prevent further admissions, manage risks to the public and avoid a more damaging breakdown in Ashleigh’s mental health.

Our mystery mental health worker writes about time management and complex team processes.

In community mental healthcare we have a lot of visits and meetings to fit into each day and it does not help that there is nowhere to park. We did have several small community bases with convenient parking, but these old Victorian properties cost too much to maintain. The new hospital sites all charge for parking, if you can find a space. Getting about is now more difficult and to ease the pain I listen to podcasts; while stuck in traffic or waiting for the train. I recommend Claudia Hammond’s All in the Mind: I always seemed to catch this programme half way through on the way to my last call of the day, but with the podcast I can listen any time.

I learnt about Complexity Theory this week, in another Radio 4 podcast. A complex system was described as something that has different outcomes, depending on the point at which the system starts to run. Apparently, if someone gets out of bed just five minutes late a chain of events can cause problems; missing the bus, getting to work late, not getting on top of tasks, and so on. Perhaps that’s why am getting to work earlier and earlier. But I was delayed one morning this week. I had not checked my emails and did not pick up messages before driving to a discharge planning meeting; only to find that is was postponed.

I had also missed the morning handover meeting and that is never a good idea. Sometime later that day I called on a service user to make a routine visit. His mother was surprised to see me as he had been admitted the day before. So I was not looking or feeling very professional; I could have spoken to him at the hospital if I had known.

Community mental health teams are a complex system in which there are many conflicting agendas and targets. Our handover meetings are crammed with information sharing as everyone is trying to work with each other to achieve multiple outcomes. I struggle to hold all this information in mind as I try to set priorities. Surely if I start each day with a rational plan I would be able to meet the targets I am set, but somehow it never works out that way.

Maybe I am just trying to be positive about my disorganisation but having time to waste on the ward is helpful. Falling into conversations in an unstructured manner is of benefit. Review meetings often run behind schedule and while waiting I chat with ward staff, building relationships which help ease the tensions. We are caught in conflicting agendas, often they want to free up a bed and I want to take time to get the discharge arrangements right.

On the day that the meeting was postponed I fell into conversation with a patient, Robert. He is referred to our team and admissions are a good time to engage, as symptoms become more stable and needs are met. I was filling time with nothing to do so my conversation with Robert was quite slow and unpressured. I believe that I learnt more about him in that twenty minutes than in all the time I spent reading his files, or assessing him by asking formal and structured questions.

Assertive Outreach is supposed to be targeted at people who have not engaged with standard community services. We were told that Robert had not engaged, but from his perspective, no one had made much effort to get to know him or help him meet his needs. Several of his appointment letters had gone to the wrong address. He had contact from a series of duty workers who all repeated the same questions. Perhaps people like Robert are failing to engage because our community teams are so stretched that an adequate service has not been provided.

Failing to engage with community mental health services is not only an outcome of a ‘lack of insight,’ or ‘non-compliance with treatment.’ People might sometimes disengage because these services do not appear to them to be of any value. So should I refuse to accept Robert as a referral and insist that the Recovery Service try harder? Well we have been working very closely with colleagues in this Recovery Service. Many of them had been off with stress related illness. Managers are talking again about integrating the Assertive Outreach Team with the Recovery Service but I hope that we can find more creative solutions.


Our mystery mental health worker writes about difficulties in engaging people while meeting service targets.

We heard last week that a former service user, Joe, is back in town. He has been seen wandering in and out of the local shops. Most people will view Joe as a typical homeless beggar, with his wild long hair, his beard and his multiple layers of clothing. But some members of our team nursed him years ago in our psychiatric hospital, when his appearance was very different. Back in the day Joe was successful, running a local business, with a ‘work hard – play hard’ attitude. It was the excessive use of alcohol and substances which led to increased admissions.

This week Joe called to me as I walked through town, he seemed pleased to see me. We spoke about the different towns he visits and he wanted news of fellow patients he knew from his time on our wards. Now and then when his attention wandered he made an odd twitching movement with his head, he seemed to be spitting out half articulated swear words. I asked him if he needed anything; should I arrange for him to see a doctor? Joe said he was fine, no problems at all, and he certainly did not want any of our medication.

Back at the office I wondered how to record this contact. Joe is closed on our electronic records and opening his case would trigger a possible breach in the Trust’s contract with commissioners. We would need to have an assessment recorded by a certain date and a care package agreed. Joe would come under Cluster 16, Dual Diagnosis. He should be offered interventions such as motivational interviewing, physical healthcare checks and treatment for psychosis. I had noticed, however, that his most pressing need was treatment for his feet. He was clearly in pain when he walked. One of our nurses mentioned a Podiatrist who sometimes treats patients in a room at a local drop-in. A referral would be needed via a G.P., but Joe had been taken off his last G.P.’s list when he caused ructions at the surgery; he is hard to manage when he is intoxicated.

In handover we recalled that in the past Joe was popular with his outgoing personality and his tall stories. However, friends and family fell away as his drug and alcohol binges grew longer and his business suffered. But he had always played the fool and he treated detention under mental health law as just one big joke. In their talk team members were almost collusive, celebrating Joe’s skills in subverting the system, beating the tax man, making money for nothing and scamming his way out of trouble. For example, when he was told that he suffers from psychosis he used this to avoid prosecution for benefit fraud. He explained that his claims for multiple benefits, under different names, were a consequence of his delusional belief that he was several different people.

When he was last in town Joe was denied support from mental health services. It was thought that he was inducing psychosis through this use of substances, or faking symptoms to gain advantage. He is not an easy man to help and if you do not give him space when he shouts he will hit you. But during a brief stretch in prison, his failure to manage led to him being treated and he accepted help. He was placed on discharge in Supported Accommodation. This time Joe was grateful, emotional even, and he cried when we put him back in contact with members of his family. Things went well until we helped him reinstate his benefit claim. A large back payment arrived and Joe could not resist returning to his party lifestyle.

We have some targets to meet around physical health. If we take Joe onto our caseload we must record that he smokes and that we have offered him support in smoking cessation. We need to record his BMI and, while he is clearly stick-thin, if he were overweight we would need to record our efforts to promote healthy eating and regular exercise. These targets make sense somewhere in our management structures but they are not going to enable us to help Joe.