Fighting Monsters

Last week was quite a difficult one for me, work-wise. I’ve already mentioned a couple of the Mental Health Act Assessments I did a few days ago. There was another one yesterday and it was the most troubling I have been party to.

At the moment, I’m still a little raw. I’ll say is that, even though I was not alone in the process (I’m still at that stage post-training, pre-warranting when I am supervised), the supervision really is back-seat as I need to establish that I am able to carry out the role without the supervision. Yesterday felt like that, but the difference was, I knew the person I was assessing well, and he knew me. I’ve visited him and his family many times - offered help and assistance according to a good strengths-based model - worked on needs as he presented - all very fine and admirable person-centred work if I do say so myself!

I even persuaded him to come to hospital as an informal patient when I saw he was deteriorating to what I considered to be a critical level. I saw him and his family through that initial period of his first experience of a psychiatric hospital. And then, after a few days, he decided he wanted to leave.

boliston @ flickr

During the Assessment, I still had to take that formal role, introduce the assessment, explain the process to him. He first asked me not to section him. Then he pleaded with me, and then he begged.  Please don’t do this to me. He said. Repeatedly. You can’t do this to me. He said, sobbing. How can you do this to me.

Before the assessment, in my heart, I’d wanted him to be a bit better. To come back round to the informal admission route. I actually really really didn’t want to write out the papers (n.b not sign them - I still can’t sign them.. ).

You can’t do this to me, he said.

But we did. And I told him after the decision had been made. According to the training, that is a part of the role of the Approved Social Worker.

His wife was with him during the assessment and she handed me a piece of paper afterwards, asking me to phone the children and let them know. I did that. They, along with his wife, agreed that it was what he needed. The interview established absolutely no doubt that  he was desperately unwell and needed to be in hospital.

To me, it was a difficult day.

I have considered, pondered, reflected on it a lot.

The most difficult thing, I think, was that the role seems to conflict with all the values that I have worked with in the.. oh.. 8 years, since I qualified (I feel old now!). I have spent years working to a person-centred model on the basis of consent (as far as possible) - persuading, building therapeutic relationships, working to empower people - and then this. It seems to conflict with all that. It is an area of Social Work so different from any I had been party to previously - I spoke to one of the managers about it yesterday, and he reminded me that it is sometimes the same in Child Protection work, or in Forensic work. I reminded him that although that might be the case, I haven’t worked in those areas so FOR ME it is something new. Sure, I’m not the first social worker in the world to experience these feelings, but they are new FOR ME.

The other aspect I considered was about the role of power in our job and relationship.

The assessment was very much an obvious and opaque display of my power over him. The different levels. When I visit at home or in other capacities, I chat and I smile. I try to pretend that although I’m there to help, it is all consent-based.

In the Mental Health Act Assessment, it’s about power. I can detain you. Whether you consent or not. It jumps out at you. You say the words, explain the legal positions and all of that contributes to the power imbalance. You try and do the best you can to establish a relationship after that to get the information. But the power is obviously disproportionate. And it feels uncomfortable.

I am confident in the decision that was made. But holding onto the implications of that decision to detain or not, is something that is crucial to the process. It was not and is not done lightly. Not by any means.

Of course, the power imbalance is always there in the relationship and has always been there. You can hide it in ‘person-centred’ words but in the end, I’m still an ‘agent of the state’, even with scruffy shoes and jeans.

It just became all the more obvious yesterday.

This week I completed two Mental Health Act Assessments (not on my own, of course, I’m still not warranted!). So I probably don’t need to elaborate on the fact that it’s been quite busy.

Just a few aspects as I saw them.

I spoke to one patient’s mother before first assessment as is required by the Mental Health Act. She was his nearest relative. I needed to ensure that she knew was what going to happen and although we were looking for an admission to assess and therefore consent wasn’t required, I needed to consult and obviously wanted to make a very hard and difficult situation as smooth as was possible.

She was sobbing audibly as I spoke to her. I explained with as much gentleness as I could muster that we would be visiting and who would be there, how long I expected that we would be there and some of the things that we would be doing and saying.

I explained that we may bring her son into hospital - and she agreed that she felt he needed it. She was worried and concerned but repeated to me that ‘I never thought it would come to this’.

She was present during the assessment - still sobbing. I’m glad we didn’t need to use the police. She helped her son pack his bag. Fortunately she lives near the hospital. Her son actually thanked us, as we left him in the hands of the wonderfully sensitive nursing staff who were able to address his concerns and worries - one by one without rushing him through the admission process. That took me aback a little bit. Of all the reactions I have seen, I never really expected to be thanked.

The other assessment, we couldn’t locate the patient’s mother. But she was very clear she wanted no contact with any members of her family to be made so apart from checking with GP, hospital, back through all the records we had - social services as well as health, we couldn’t really do anything more. We didn’t even have a name to go on.

But as it happened we didn’t admit her anyway. It was an interesting assessment as both medical recommendations had been signed. It wasn’t the first time that I haven’t admitted someone following an assessment but it was the first time that I hadn’t in the face of two medical recommendations.

I think in some ways the assessments that don’t result in an admission need a lot more consideration as the risk assessments need to be very clear. Especially if the medical recommendations are in place.

The new Mental Health Act Code of Practice is going to be (so I’m told) far more explicit about not using the threat of an admission under the Mental Health Act as a way of trying to affect behaviours, so, for example, it will not be acceptable to say

‘We have two medical recommendations and while we won’t admit you now, we can come back and take you to hospital if you don’t take your medication’ (i.e. sign the admission papers).

This is something I was very mindful of during the second assessment as we spoke, specifically about coming back the next week to see how things had developed but we (myself and the ASW there) spoke about how we could present this without it being a threat. I’m quite confident in my mind and regarding the reaction that it was not presented and perceived that way.

But I am going back next week..

Yesterday, I met a old friend for lunch. She is also a social worker - in fact, she was the person who persuaded me to do the MA in the first place. We don’t meet as often as we probably should (work, distance, children) but it’s always a good chance for reminiscence.

It brought back to me some of the reasons I decided to be a social worker in the first place though and they aren’t necessarily the same reasons I gave in my interview for the course!

a) 9am - 5pm Mon-Fri work. I’d been a support worker in residential care for about 6 years. I was tired of shift working.

b) Some kind of mental stimulation. In a lot of ways, I enjoyed the hands-on care work - indeed, I did it for long enough to have had the opportunity to change if I didn’t and sometimes, even now, I miss it. The feeling of having a positive effect is much more real in a sense and you build very strong relationships with people for whom you work and the power dynamic, although still present, is much less intense- but sometimes, I felt that the intellectual challenge was missing.

c) Pay. As much as I liked being a support worker, I lived on my own in London. My pay quite literally doubled when I qualified (so you can imagine how low my salary had been!).

d) Vague and woolly helping people and social justice notions floating around in my head. I was more of an activist (not really politically but socially) coming out of full time education the first time round. I think I did genuinely want to make the world a better place (I still do, of course, but in a less flamboyant manner!).

e) My friend said it would be good to do (possibly this would come higher up on the scale)

f) I would have some kind of ‘professional qualification’. I had notions of moving abroad/travelling the world and wanted to have some kind of ‘professional status’ that might make it easier. I wanted to be more adventurous than I actually was (as an afterthought, I actually did end up doing this - best thing I ever did!).

So in reflection, most of the reasons have changed more or less along the way. I am so glad I did it though. The course itself changed me in a lot of ways even before I started practising and possibilities have opened up that I hadn’t even known were possible previously.

el ramon @flickr

I have been and continue to be involved in my local Care Ambassador scheme where I go out into local schools and universities and assist with career days usually and try to explain the joys of a career in social care to people who are still at the planning stage.

It has been an incredibly enjoyable experience and I’d definitely recommend it. In some ways, I have been surprised by the responses and how positive they are.

One time when I went to one of the more traditional old-school (so to speak) universities at a careers event which was sponsored by a Merchant Bank in the City of London. All smoked salmon canapés and champagne.

There were representatives of some of the major banks in the City, legal firms, management consultants - and there was my stand, with a teacher who was standing with me in solidarity, I think!

I really was genuinely surprised at the amount of interest that was expressed and even if none of the many people I spoke to that night actually go into the field of social care - at least they have an idea of what the work involves that I hope they’ll take with them.

So although the reasons for doing this job might change but there are still reasons. I just need to refocus on them from time to time.

One time, when I was fronting a Mental Health Act Assessment during my ASW training, I was sitting in the ambulance next to a women whom I had just assessed and opposite us, was a police officer.

She turned to me, and asked me directly ‘What do you enjoy about being a social worker?’ while looking me directly in the eyes and leaning in towards me, her face just centimetres away from mine.

I said something vague and rambly about ‘helping people’ - realising the horrific irony in the fact that we were transporting her, against her will, to a psychiatric hospital under a section of the Mental Health Act.

I cringe slightly when I think about it still. I need to come up with a better and snappier answer.

A completely self-serving and indulgent post if I can be forgiven, so I’ll keep it brief!

It’s Sunday, it’s a holiday weekend and I’m fairly busy but I did get a letter yesterday from the university confirming that the portfolio for my Approved Social Worker (ASW) training course has, quite literally, ticked all the boxes - and is being recommended for a pass.

It wasn’t easy but it possibly isn’t worthy of too much reflection as there won’t be any more ASW training. Next time round, it moves out of the exclusive domain of social workers and into the realms of Approved Mental Health Professionals….

In order to become an Approved Social Worker (ASW) the requirements are as follows

- undertake a course of sixty days training (a mixture of lectures, seminars and supervised practice in a placement setting )

-apply for a warrant (after some more supervised practice, written work and an interview) which lasts for five years, from the local authority. There is a requirement for ongoing training throughout the time that the warrant is held.

So the usual process is that after I submit my portfolio of work - I return to my usual workplace and am asked to complete a certain number of assessments in conjunction with an experienced ASW.  I have to produce a report reflecting on these assessments and take it, along with my portfolio (marked) to a panel made up from the Trust (usually, the Trust lead for ASWs and the Director with overall responsibility for Mental Health Services) where there is an interview of sorts to determine whether I will be issued a warrant.

I have to say I was somewhat reluctant to attend the course in the first place. I understood that it would be expected of me, but didn’t feel quite ready. In the process of discussing these concerns with my manager, I was reassured when I was told that there would be no rush to warrant me after the course. I should go and study so that the training part was out of the way and then I would be given as much time as was needed before I was actually warranted.

Yesterday I was informed, indirectly that the date for my warranting panel has been set, and it will take place next month.

This is somewhat surprising as a relatively conservative guess of when it would be taking place was August at the earliest.

Of course I could refuse and ask for more time but I’m not sure it would serve any purpose at the moment.

There are more than a few political issues going on behind the scenes and I can’t help feeling like a bit of a pawn. There is a massive shortage of ASWs  in the team that I currently work in. There is a lot of annoyance in some other teams that they are ‘taking’ our work on. They have attempted to refuse to carry out assessments that have been asked for but have been railroaded by management to do them.

I expect that is why I am being rushed to warrant. I feel a bit ambivalent at the moment about it. I don’t feel as insecure as I did - the training was extremely thorough and I had excellent experience in practice through my placement that could not have been more supportive. I suspect the idea is that it will provide a better quality service to the people I work most closely with which can only be a good thing.

In some ways, I want to just finish off the process so I don’t have to think about what I need to do next.

I am also aware that my position in the team has changed ever so slightly. I mentioned to my managers something vague about not being happy and they immediately became ever so defensive and concerned about me wanting to leave. I am not desperately surprised as the cost of the course I have just completed would enter into thousands of pounds.  I don’t really have any intention to leave. I like a lot of aspects of where I am. But things seem to be changing around me and very quickly.

Interesting times, indeed.

Just when I thought I was pretty hot on all the acronyms that are flung around the workplace, I have been hit with a few more. It came as a result of a conversation with one of the managers (there are whole swathes of different levels of managers in the local authority that become very difficult to unravel ) who informed me I would need to go to Dols training to be a BI assessor early next year.

I couldn’t actually understand what she was saying at first and then she explained that she was talking about Deprivation of Liberty Safeguards (which, apparently are known in the circles as DoLs) and being a Best Interest Assessor.

Of course, I had expected it would be something I’d be doing, as I work generally with older people and have just come off the ASW training so tick the boxes.

It certainly sounds, at least initially, less troubling morally than being actively responsible for detention of people.

I have though, become acutely more aware of it and the need for a robust Human Rights Act since working with compulsory admissions to hospital - and with the Deprivation of Liberty safeguards due to be implemented in April 2009, it’s an interesting development to turn back to.

The implementation is the DoL safeguards is very overdue as the Bournewood decision was handed down by the European Court of Human Rights in 2004.

It has been a long time coming but a few years later, there will be some kind of recognition that people who lack mental capacity need additional safeguards if they are held in hospitals, residential care and other ‘care’ facilities, without being able to give their consent.

Currently, as far as I know anyway, the plan is to train up some people who work within mental health teams to reassess people who have been placed in residential/nursing care or long term care without being able to give their consent and assess their Best Interests in respect to this and ensure that the placements have been made in their best interests.

As well as assessing best interest, a number of other criteria are specified including a separate assessment of mental health by a different person (a doctor) to verify that there is a mental disorder that warrants the level of care that is provided.

It has the potential to provide a more formal advocacy role and the hope of being to put into practice one of those wooly goals of ’speaking up for those without a voice’ ideals that drew me to social work in the first place.

Although well overdue it has the potential to provide some kind of voice for people who might not otherwise be heard and although there is the usual heart-sinking response to anything that seems to involve more paperwork/assessment and administration anyway, I am hoping that in this case, it will be able to affect a better standard of decision-making all round.

I finished my portfolio for my ASW course yesterday. It’s the last time the ASW course will run because the next lot in the autumn will be doing the AMHP training. And it got me thinking a little bit…

Naturally we spoke a little about the change while we were training. General consensus - that social workers are a somewhat precious lot who have little faith in nurses to remain as independent as they do in Mental Health Act Assessments and in the face of dissenting doctors! (because, realistically, nurses are likely to be the only other professionals who do train as Approved Mental Health Professionals… )

I think it depends very much on the individuals involved, of course. Some doctors can bully anyone at all, be they nurse, social worker or magistrate - just as some nurses or social workers can. Power is a massive issue though. Doctors, I think, whether they like it or not, and want it or not, have a more natural recourse to power than most professionals, due mostly to the close contact that most of us have with them (I don’t think anyone hasn’t seen a doctor!).

Generally, I’ve always thought that it will be a difficult jump from medically trained professional to AMHP, because the emphasis is considerably placed on exploring and examining the social causes and catalysts of mental ill-health. I am also more concerned about the independence, generally, of medical professionals in carrying out the role and have always felt (perhaps it’s some of that professional protectionism… I never said I had to be rational!), that the training ethos of social work adds something very different to Community Mental Health teams that isn’t present in any other discipline.

Of course, on a real level, all the work in CMHTs, certainly ones I have come across, is more or less generic and this is just further recognition of that.

Social Workers, Occupational Therapists and CPNs sit side by side and the workload doesn’t really change although I’d like to think that each professional is able to add to the whole, rather than conglomerate in a mass of ‘mental health professional’.

Truth is, there are too few ASWS and it was a change that needed to happen. Likelihood is, the end result will be positive as there will be an enhancement in the professional status of those who want to enter this area of practice and the wider the pool the more likely the cream may be to rise to the top. Although a part of me is a little suspicious of anyone who actually wants to carry out Mental Health Act Assessments…

n.b. The title of the post is making the assumption that I’ll actually pass the course and get warranted.. !

One of the things that was emphasised strongly on the course, is that someone should never be admitted to hospital under compulsion because they ‘refused to take medication’. That just isn’t a reason to apply for an admission.

It seemed to be almost natural to comment on that in the assessment papers but, as our tutor pointed out, not wanting to take medication which may have horrific side-effects, does not, in itself prove anything if you have no idea what the background to that refusal is and why the medication might be refused.

Our tutor felt it was a part of the move towards the medicalisation of the social work profession (if that’s a real word!) that we were accepting what the psychiatrists were feeding us - namely by refusing medication that would make you ‘better’ you must be crazy.

That thought, combined with one of the more powerful and useful lectures, by a man with a diagnosis of schizophrenia who spoke in the most powerful terms possible, of the pain that the side effects of medication had given him and his fear of being medicated, made me consider how I have approached medication in the past and the emphasis on it.

There is no doubt that medication is important. It is more than important - it is vital. But there’s usually more than one way to skin a cat, so to speak. It is only one of a range of therapies that can be useful and valuable and productive.

I hope that it is not a lesson I forget in a hurry as sometimes, we can be caught up in doing what we think is the right thing to do and stop listening to what the difficulties actually are because we are superimposing what we imagine them to be.

Moving into the final stretch now and I’m wavering between feeling fairly confident and feeling completely incapable of finishing off the work. I think I’ve got things in hand more or less - but then I worry about the pieces that I haven’t done yet and how long they’ll take. I’m feeling for the first time though, that I’ll have something to hand in, even if it isn’t great!

Yesterday was the last day of the ASW course - well, the last ‘official’ day. It was funny but I spoke more to some of the people and on a more ‘real’ level than I had during the last few months!

Anyway, the Presentation went OK.. not great but not awful and it’s done now. In retrospect, I think the poems at the start weren’t the best of ideas but it could have been worse!

One of the presentations was excellent and it was by a participant who was really nervous so I was so pleased for her. I realised that being genuinely happy for another person is actually great!

Anyway, now the massive push starts - I have a lot of writing to do and not enough time to do it but I think this is where the deadline-buzz kicks in.. at least, I hope so!

(just as a sidenote - the two poems I used were by Elizabeth Jennings and were called ‘The Interrogator’ and ‘The Night Sister’)