Category Archives: ASW
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I think there’s a lot of misunderstandings about what I actually do at work. What do social workers who are in mental health services do? What do social workers who work in adult services do?
I hope by reading, some people get to learn a little of my day to day role but I also thought it might be useful to set it out more explicitly.
I’ve worked in adult services and I’ve worked, as I do now, in mental health services but I’ve never worked in childrens’ services so I can’t comment at all about the work that is done there. This is my attempt, not to explain social work as a whole, but to explain the bit of social work that I’m familiar with.
I work in a multidisciplinary Community Mental Health Team. We have a consultant psychiatrist attached to the team as well as a few (the amount fluctuates!) other doctors. We have occupational therapists, clinical psychologists, assistant psychologists, community psychiatric nurses and of course, social workers. We always seem to have students around, whether psychology trainees, OT students, nursing students or social work students (and even some medical students pop in occasionally). I sit opposite a psychologist and between an OT and a nurse.
Although no week is typical, I’ll give a few examples both of the generic role and the way that social work fits into a mental health setting, in England, at least (because I’m not sure if there are differences in Scotland, Wales and Northern Ireland).
Work is allocated for ‘care co-ordination’. Care co-ordination is akin to what we would have called ‘care management’ in Adult Services although there are some differences and responsibilities under the Care Plan Approach. It basically means we take responsibility as a kind of ‘key worker’ for individuals who are ‘taken on’ by our service.
Allocation should be done on the basis of appropriate professional expertise so for some issues that have a more ‘social work’ tilt about dynamics, organising personal budgets or residential placements might be preferred as allocated to social workers, some that are more rehabilitation orientated might be allocated to an Occupational Therapist and more medical or medication management might be allocated to a CPN but that is a very broad brush to paint and in practice – most people are a mixture of all the different needs and so are allocated generically. If I have need a of specific OT assessment for one of the people that I am care coordinating, I will ask one of our OTs and similarly, I care coordinate one person who receives a monthly depot injection from one of my nursing colleagues.
So what is care coordination/care management about? Well, we start by working with and on a care plan and this should be led by the user of the service. If there is a carer involved it would also involve them and we put together plans. In my service which works predominantly with older adults, there may well be care services needed and this is now all delivered through personal budgets so I would take someone through the supported self assessment questionnaire, the resource allocation system and develop with them and/or their carers, depending on capacity issues on a support plan and way that services would be delivered. This would be reviewed and implemented in partnership.
I will also arrange respite placements and services when they are needed and review services as they are delivered.
Alongside this, I would also be responsible for monitoring any changes in mental state and might provide some brief therapeutic interventions mainly through basic CBT type models according to additional training which has been given in the NHS Trust I work in as they are trying to ‘skill up’ all care coordinators! When I meet with someone, my discussion ranges for more broadly than about their care needs specifically. Sometimes it is about sourcing and finding ideas, services and people that might be able to help, namely through group work which is run across the service or through referrals to specific psychologists attached to the team. Sometimes it is much more difficulty to quantify – and log – and record.
I work with carers and work through carers’ assessments and services such as they are. Often I feel one of the most important aspects of my work is carer support as we rely so heavily on some carers. I might liaise with different organisations on peoples’ behalf if they can’t manage or need some assistance. Sometimes I help with Attendance Allowance or Disability Living Allowance claims but there are council teams that do that so it would only be in circumstances when I might know someone particularly well and be concerned that someone who doesn’t know them that well might ‘underplay’ some of their needs.
Sometimes it is about liaising with creditors, gas and electricity companies, housing etc with various degrees of success. I like to think of myself as an advocate at times.
Although at times, I am very far from an advocate. I am subject to specific ‘terms of reference’ of my job and have no control over things like budgets that can be assigned to various people with various needs. I would ‘present’ the needs of service users I work with to various internal funding panels so on that basis I need to advocate clearly.
We have to review the services that are in place regularly. I would attend meetings at day hospitals and on wards when I am allocated to people who currently attend or are inpatients.
I work to plan and organise discharges from hospitals both the psychiatric hospitals and the general hospitals when people whom I am allocated to are inpatients. There are some very obvious time limitations on these pieces of work and no-one wants anyone to be in hospital any longer than they have to – but equally no-one wants someone to be discharged from hospital before they are well enough to be – which is another very important consideration.
I conduct safeguarding investigations as well. Alerts come up with what can be surprising frequency and there are prescribed procedures through which we approach these investigations. It’s hard to generalise as they can be very different. Interestingly most of my recent ones have involved residential services in some way or another. I think I’ll come back to the process of investigating abuse in another post as it is altogether a subject in its own right. We tend to get more of these investigations in older adults services than occur in the working age adult services.
I am an Approved Mental Health Professional (AMHP). That means that I am on a rota to carry out Mental Health Act (MHA) Assessments . There is an important difference between a Mental Health Assessment which is a more generic term for an assessment of someone’s mental health and a specific ‘Mental Health Act Assessment’ which is a formal assessment under the 1983 Mental Health Act which can result in a compulsory admission to hospital without consent.
The role of the AMHP could be a post all of its own and it probably should be so I’ll condense here for clarity because it has increasingly become a part of my day to day role. I organise and arrange these assessments by arranging for ambulance service and doctors attendance (there have to be two medical recommendations written by doctors – one should know the patient (usually their own psychiatrist or GP along with an independent doctor who has had additional training). I also attend a magistrates’ court to obtain a warrant to enter if it is likely that we would not be allowed access to a property. I arrange police support if necessary and would also organise a hospital bed if necessary.
There are legal forms to complete and I have an obligation to be mindful and respectful of legal rights and human rights when involved in these processes. I am obliged to attend a specified amount of ‘legal updates’ every year to maintain my approval as an AMHP and every five years I have to be ‘reapproved’ which involved me taking a legal test and submitting some reflective pieces and examples of my work as well as carrying out a set number of assessments per year (no problem with the numbers – I’ve done the requisite annual number in the past week!).
I’m also a BIA (Best Interests Assessor). This means I have specific duties and responsibilities to carry out assessments under the ‘Deprivation of Liberty Safeguards’. Again, that probably demands a post or two of its own. Suffice to say that every so often I am called out to do a specific type of assessment on this basis. I had to attend additional training to be able to do this and have to attend update workshops and training to retain my approval.
Apart from the things I’ve listed, my job involves other pieces of work. I write social circumstances reports for tribunals. I occasionally have been involved in assessments and writing reports for Guardianships and in taking part in the process of approving or extending a Community Treatment Orders. I frequently carry out Capacity Assessments for various reasons.
I’m a practice assessor too so when I have a student, well, I have a student to supervise. I tend to enjoy having students around. It does create more work though and there’s no recompense in terms of reduction of caseloads! And the universities and local authorities wonder why we can’t offer as many statutory placements!
My work is often one of juggling and trying to prioritise and reprioritise on the basis of risk management. What is more important for me to complete on any given day.
I haven’t even mentioned data input or writing case notes but takes a fair bit of time. We have regular audits of our ‘productivity’ – we have to input our ‘outcome measures’ and re-input them regularly so our management overlords accept that we are actually spending our time at work, working effectively and not just twiddling our thumbs and playing Facebook games.
The amount that we have to ‘report back’ is, of course, growing at an exponential rate.
So that is my job – as briefly as I could manage and I have missed out some of the million subtleties that might change on a day to day basis.
I generally enjoy it. I love the variety that is thrown my way on any given day. Some days it frustrates me and there are rarely enough hours in the day to get what I want done, done. This may explain some of my frustration with the bodies who all say they ‘speak for social work’. Have they explained the role of social work outside child protection? Would you know, if you are not involved in the ‘system’ what a mental health social worker actually does?
But really, that’s another fight for another day. For now, well, I need to go to work!
But I had over to you, dear reader. Is there anything that surprises you? What you expect? What have I left out – as I’m sure I have missed a lot of things!
Tags: AMHP, approved mental health professional, cmht, Community mental health service, health, mental health social work, mental health, mhsw, NHS Trust, social work, social work in the uk, social worker, what does a mental health social worker do, what does a social worker do
Sometimes, some days feel filled with sadness. I had one of those days this week. I don’t like to use the word ‘hardened’ but to put it this way, in over 10 years of frontline social work practice in some of the most deprived areas of the country and in the inner city, I’ve seen a fair bit of what society has to throw in terms of crumbs to those who are some of the most vulnerable members of it.
I look at the high rises that skirt around the cities and I see hundreds of lives being lived, families existing and stories being told. Some with hope and pride. Some with desperation and despair. All different, all a part of this community and society we live in. Poverty is real. Despair is real. The two don’t have to go hand in hand though.
I have a strong stomach and don’t bat an eyelid at all sorts of things when I walk into a house. I’ve probably seen worse.
In some ways, human misery is a part of my trade. Not always, of course, because there are the wonderfully reassuring smatterings of hope but difficult social circumstances and social deprivation run a theme through my career.
Although I often emphasis that mental ill-health is certainly no respecter of social class or financial assets, it is sometimes the level of deprivation and the difficulty and shame of poverty that I see that reminds me of the way that this political class intentionally ignores and isolates some members of the community.
Perhaps the most difficult part of my job is wrapped up in the AMHP (Approved Mental Health Practitioner) role. It is a mirror into my ethical compass and while I enjoy the aspects that were involved in training and the support and development and even community feeling I have with other AMHPs, the process of making a decision about someone’s forced detention in hospital or a forced medication regime is never one that can be taken lightly and I don’t think it is one that should ever be ‘enjoyed’. It is power, writ large. It is control.
Sometimes people thank you retrospectively for ‘making the right decision for me at the time’ but more likely that isn’t going to happen.
This week, I carried out a Mental Health Act Assessment in a hospital. That is very far from unusual. When I read the background and the circumstances, when I conducted the assessment and made the application for detention, which I did, I was overcome with a feeling of sadness for the action that I had taken and for the life that it predominantly affected.
For obvious reasons I won’t go into details – anyway, even if I did they would possibly sound fanciful and unrealistic. To people who think that I have a ‘difficult’ job, I would say I have had a walk-on part among some fine and very strong people who have had to contend with sickness, pain and family circumstances that have rolled all the dice against them in the lottery of life.
And when I sign the papers and write up the report, I don’t forget. I think, I reflect and I try to learn. What could we have done to prevent this situation from having occurred? Sometimes the answer is nothing but sometimes there might have been a different path, a different action or different guidance that might have led to a different outcome.
Sometimes, some days, I just feel overcome with sadness. Sadness at the injustices that are meted out by life, fate and circumstance. Sadness at the way that this society perpetuates and builds on those injustices of circumstance. Sadness at my role my own complacency in accepting that we have created such an unequal and unfair society.
In a community where people who live on state benefits are treated with an intention to humiliate and scorn and where the government not only condones and supports this, it tries to create further barriers between the ‘haves’ (with ‘have’ meaning working tax-payer) and the ‘have-nots’ (meaning those who depend on the state for income) it sickens me as I know that the rhetoric of ‘choice’ and ‘community capacity building’ are empty words which mean nothing without the world of privilege. By privilege I don’t mean money, necessarily, but include the privilege of having family or friends around, the privilege of being well enough to build up networks of support, the privilege of being a part of a community. There is so much more to privilege that cash assets or income.
Sometimes I want to shout against the system that I am a part of. The social care system in this country is not ‘fair’ – it reeks desperately of unfairness and the pushing of ‘choice’ in very narrow terms onto a wide range of people who in reality have no choice whatsoever further marginalises and discriminates against poverty, incapacity and isolation.
But I continue in my job. I go into work and ‘buy into’ the system. In my own defence, I fight as hard as I can from the inside and I don’t forget the names, the faces and the stories of those whose lives touch mine.
I remember, I note and I learn and sometimes, that just fills me with sadness – but when I stop feeling that sadness, I stop learning, growing and trying to create a better world. One person at a time. In spite of the system I work in and with rather than because of it.
Community Care carries details from the GSCC (General Social Care Council) annual report on social work education in England and it shows a fall in the amount of social work placements provided by local authorities. This came as absolutely no surprise to me.
According to the article, two thirds of social work education providers were asked to improve the quality of the placements that they offer to students. The absolute figures show a fall in the amount of local authority placements provided from 6,546 in 2007-8 to 5,986 in 2008-9. This has, within the sector, long been seen as a problem as universities have increasingly found it hard to find placements.
There are two issues that though related are not entirely equivalent. One is about the fall in the availability of social work placements provided by local authorities and the second is the more general fall in the quality of placements provided.
The relation is that local authority placements are often sought as the ‘better’ placements. I’m not sure that’s entirely true for the record but the Social Work Taskforce suggested that all social work students should ideally have at least one ‘statutory’ placement (a statutory placement does not have to take place within a local authority).
Having, since qualification, worked solely within local authorities, I would say that it doesn’t automatically follow that local authority placement equals good placement. It may on paper but the quality of the placement depends on the individual practice assessor/workplace supervisor and what they are able to give and bring to the teaching process.
Saying that, there are reports of some wholly inappropriate placements knocking around.
Personally, I could have taken a student this year. I was asked to. I refused. I loved doing the practice assessing. I will again but honestly, I have no idea what my service will look like in four months time as we have another big reconfiguration coming up. I didn’t think that it would be fair to have a student with all the uncertainty about where our jobs will lie. I expect this is fairly common within adult services at least.
I asked our borough’s placement co-ordinator if I could be a ‘long arm’ or off-site Practice Assessor and she said that would be a possibility but the only workplace supervisors available came from Childrens’ Services. With the upheavals in the very near future, an massive workload due to a very very short staffed team, it seemed like too much of a jump for me.
I just didn’t feel that comfortable taking a student who was working day to day in Childrens’ Services. So I declined. I hope to be able to offer a placement later in the year when we know some of the longer term impact of the local authority settlement and to put it brutally, which services will still be around.
I doubt my consideration is unique.
I read through the GSCC report and there are a number of other interesting tidbits contained therein.
The amount of social work students has risen to 6115 (2009/10) which, they say, is the second highest since the degree was introduced. Hmm. Perhaps I see a link with the lack of placements. There was also a decrease in the amount of workplace sponsored students. Again, another indication of a potential problem with finding an absolute number of placements as sometimes workplaces which sponsor students will provide equivalent placements.
There were some interesting points about PQ (post-qualification) courses that the GSCC monitor as well.
I am a little ambivalent about the new PQ framework. I have a full PQ (1 – 6 to those who remember it!) qualification on the previous model. That combined my PQ1 with my ASW training.
My Practice Assessor module took place under the ‘new’ system and I am glad I was able to take the ‘longer course’. I have accessed more training than most though and I’m aware of that.
The figures that 11% have enrolled on a PQ course wouldn’t worry me overly just because it won’t count all those members of the workforce who have completed PQ training under previous guises.
I wasn’t surprised either that 55% of registration for PQ training was in Children and Families (they get more funding for training than adults services in our borough at least and have been rolling out with the NQSW programme for longer) nor that those training in the ‘Mental Health’ pathway fell to 16% (from 22%).
I can think of one obvious reason for the decline. With the change in Mental Health Legislation meaning the Approved Social Worker as was, now an Approved Mental Health Professional – can come from different professions, it may be that fewer Social Workers are getting the opportunity to train through the Mental Health PQ route (which basically is the AMHP training).
A friend of mine in another borough told me that health professionals (nurses and OTs) were being actively encouraged to apply for the AMHP training in preference to social workers. This is hearsay evidence of course (although naturally I trust her implicitly) but I do wonder if Mental Health Trust prefer paying for the training of their own employees rather than social workers who are often seconded by local authorities.
The other interesting figure was the high proportion of deferments that took place on PQ courses. I would venture a guess that this is due to workload pressure.
In fact, the lack of placements, lack of enrolment for PQ courses and high deferment are all due to workload pressures in the field.
Our local authority isn’t going to be funding PQ courses for adults, including the Practice Assessor Course and the Enabling Others Courses which require that social workers training take students on placement. That’s a few more down locally. Hopefully, it is just a temporary measure through the ‘tough times’ ahead.
I have to say that I do wonder if one of the solutions is for the universities to admit fewer students. A poor quality placement is no answer and can set students up to fail in the workplace. It wastes time all round. I think that there needs to be some thought about the presentation of local authority placements as a kind of ‘gold standard’ as well. They don’t have to be. Placement is about learning the social work more globally than just a particular training for a particular job. I believe more social work will take place in the private and voluntary sector in the future. The social work degree is the end of the beginning in the training and learning process. There is no end.
I feel frustrated when students ask me about employment prospects if they have a statutory placement – really, it shouldn’t make a difference because any local authority worth their salt should be able to train a qualified social worker without depending on particular placement experience. A part of the problem is that more students come into social work without any pre-qualification experience and rely wholly on placements as ‘work experience’.
Anyway, perhaps that’s another story for another day. In the meantime, the GSCC throws some interesting figures into the state of social work education.
Yesterday, via Twitter, I was alerted to the publication of the ‘Mental Health Bulletin – Fourth Report from Mental Health Minimum Dataset (MHMD) returns 2010’. I know it’s a bit of a mouthful but briefly, it means statistics about admission, treatment and care by Mental Health Trusts around England.
There are a few tidbits of information that are worthy of comment and commentary.
The most obvious ‘headline’ figure presented is that there has been a 30.1% rise in people held in hospital under the Mental Health Act between 2008/9 and 2009/10
‘from 32,649 in 2008/9 to 42,479 in 2009/10’.
That’s a staggering initial figure for a change in a one-year period so I wanted to look at some of the possible reasons for this.
The survey itself indicates a large part of the change – being that
Some part of this increase was due to improved recording between 2008/09 and 2009/10, because a small number of trusts failed to provide MHA information in 2008/09. On a like for like basis, excluding the data for trusts that failed to return information in 2008/09, there was an estimated increase of about 17.5 per cent in the number of people being detained under the MHA – from 32,649 to 38,369
I’m not entirely confident I understand the baseline statistics but taking advice from those who know better, I’m happy to stick with that 17.5% increase.
My initial gut feeling and certainly the situation that tallies with my own practice experience is that the influence of the Mental Capacity Act has been crucial in leading to an increase in detentions that I, personally, have signed over the last year.
I understand that I might have a slightly non-representative view as I am a specialist in older adults’ mental health and primarily carry out Mental Health Act Assessments for Older Adults therefore I may see a disproportionately high number of people who may lack capacity due to organic mental ill-health (e.g. dementia).
However, the impact of DoLs (Deprivation of Liberty Safeguards) has led, through something of a drip-drip process and through caselaw – particularly GJ v Foundation Trust which established that there can be no ‘choice of law’ between the use of the Mental Capacity Act and the Mental Health Act for a ‘mental health patient’ in a ‘mental health hospital’, to an increase in admissions under the Act. Actually, I genuinely believe it allows a far far greater protection than the DoLs process allows but I might be getting over-technical. Suffice to say that there has been a substantial increase in the amount of people on the older adults wards who are now detained ‘under section’ – who may well have, last year, been informal patients.
Of course, the issue of capacity or lack of it doesn’t solely relate to older adults but the examples I give are from my direct experience.
I’ve turned down a couple of Eligibility Assessments under the DoLs framework, suggesting the people whom I have assessed have been ineligible for a Deprivation of Liberty Order because they would otherwise be eligible for detention under the Mental Health Act. I’m just one person, I know, but I know of other people in my Trust who have made similar decisions.
It may be a reason for some of the increase in detentions.
I’m not sure if the cuts agenda has had a significant impact on status of admissions yet save the generalised increased levels of distress and higher potential levels of mental illness that may occur when the economy is in a depressed state.
In our Trust there have been a massive reduction in the amount of inpatient beds available. Does that mean people who might have been brought into hospital earlier are not? Possibly. It may mean fewer informal admissions take place due to the lack of beds and therefore situations deteriorate so an admission has to be on a compulsory basis. That may also explain why the length of time of stays has increased.
The other unsurprisingly depressing point made from the data is that
Whilst the number of people using services rose across all ethnic groups, the percentage rise was noticeably larger for the Mixed ethnic group (a rise of 17.7 per cent). The Mixed and the Black and Black British groups now both have rates of access to services that are over 40 per cent higher than for the majority White group (at approximately 3,800 per 100,000 population compared with about 2,700 for the White group).
The most obvious explanation of this relates to institutional (and overt) racism and a differentiation of the way the treatment and treatment decisions are made on the basis of cultural backgrounds.
If anything needs to be actively addressed it is this inherent difference in the system and services that seem to allow such disparity to exist.
Another interesting point that was in the main document was that
‘The number of women detained under the MHA who came into hospital via the prison or the courts rose by more than 85% since 2008/9 …. The number of men in this category rose by 48.1% since the previous year’.
Again, staggeringly high figures. I wonder what significance changes to prison services has and will have on admissions to psychiatric hospitals via the court system. It’s not an area I have more than perfunctory experience of so I can’t comment in detail, except that it’s an interesting aside.
In fact, looking at the bare figures, it seems that these increases have made up a good proportion of the overall rise in compulsory admissions under the Act across the board.
As I’ve been reading through the document I came to the conclusion that I could easily cover about 10,000 words worth of analysis of the information provided!
What I would say though it that it’s worth checking the entire document because the information contained on the breakdown of admissions on the basis of gender, age and race make for lots of potential analysis and interest in the nature of work and how it is changing in mental health services in England.
Community Care have a short report about figures were published yesterday by the NHS which indicate that there has been an increase in detentions under the Mental Health Act over the last year.
As the article says
The numbers of people being detained under the Mental Health Act rose by 1,692 in the last financial year according to figures published by the NHS information centre.
The 3.5% increase brings the total people detained under the act to just under 50,000 in one year and represents the largest increase in three years.
The total numbers admitted to hospital also increased to 30,774 in 2009-10, a 7.3% increase from 2008-9. The rise was attributed to an increase in admissions to NHS hospitals, while previous increases have been driven by private sector treatment.
I thought it would be an interesting point to consider as, on an incredibly unscientific basis, I can say that I have been personally busier as regards making applications for detentions under the Mental Health Act in the last year than I was in the previous year.
It’s ironic considering we’ve had a number of wards closing in our Trust and the number of beds available has decreased.
The reason? Again, I repeat this is completely based on my own experience but I’d put it down to the impact of the Mental Capacity Act 2005 and particularly the provision of the Deprivation of Liberty Safeguards. This has led to a massive increase in the amounts of assessments I’ve been asked to complete for people who might previously have been informal patients in psychiatric wards who lack capacity to consent to admission or treatment.
Of course, this group of people should probably have been brought under the auspices of the Mental Health Act previously, on the basis of meeting the criteria for detention and despite all the perceptions and stigma associated with ‘being sectioned’, personally, I think the legal processes allow for much better protection of the individual than ‘being an informal patient’. There are various issues about how ‘voluntary’ an admission can be if someone has the threat of a potential compulsory detention hanging over their head but if there is a question of them being stopped from leaving, it has to be a strong consideration.
There is a greater awareness of issues of capacity now and that one doesn’t have to be rattling the door down and repeating ‘I want to go home’ every five minutes to be objecting to ones detention on a psychiatric ward.
There is also the sticky s117 issue which had allowed some consultants and Trusts to ‘dodge the bullet’ on making recommendations for compulsory detentions when really they might have.
s117 of the Mental Health Act ensures that the NHS remains responsible for any aftercare services provided. That may include residential and/or nursing care costs which can rack up to thousands of pounds fairly quickly.
Guidance has changed over the past few years (due to case law clarifications) and we are told that we cannot now discharge the s117 responsibility if someone has dementia as it is not likely to improve and therefore the aftercare is provided free for life.
Now, I’m not saying that these potential high costs might have prevented some informal patients being admitted formally to wards but it is a massive potential cost.
The DoLs (Deprivation of Liberty Safeguards) have led to greater awareness and training on the wards in relation to the interaction of the Mental Health Act and the Mental Capacity Act. I’m not saying that is the sole reason for an increase in compulsory admissions on the wards as I am aware my experience, being particularly in the field of older adults, is an area where this matter is much more relevant to those who might work with adults of working age, but for me, it has been the key factor in the increase in applications for compulsory detentions that I, personally, have made.
Is ‘to section’ a verb we should be using? My understanding and instruction was always that we should try, if at all possible, not to refer to ‘sectioning’ someone.
It seems a bit flippant. It seems to imply a decision made. I know these are values I am attributing to the words but I can’t escape the discomfort I feel. Then, on the other hand, it is a word that describes a process in a way that is understood.
I know that is not a rational response to reject a word out of hand but I feel quite strongly about the process and having seen regularly, the distress it causes at close quarters, trivialisation is the last thing that should ever come to mind.
This occurred to me yesterday following a discussion with a nearest relative when I was explaining about the assessment I was going to be undertaking.
Just for the record, none of the pieces of conversation below quite matched the way the ‘real’ conversation went yesterday, but they are parts of conversations I’ve had with a variety of people over the past couple of years.
It’s one of the tasks that I have as an AMHP (Approved Mental Health Professional) – and on a human level, it can be difficult. I am obliged as a part of my duties in setting up Mental Health Act Assessments to consult the relevant nearest relative in the case of an application for admission under Section 2 of the Mental Health Act and to consult and ensure that they do not object in case of an assessment under Section 3 of the Mental Health Act.
There’s that ‘section’ word again.
Depending a little on the situation and whether it might be a person’s first assessment under the Mental Health Act and how close the family member actually is, you can judge how to pace the conversation.
‘I’m going to be carrying out a Mental Health Act Assessment of your mother’ Notice the difference between ‘mental health assessment’(which could be any type of more generic assessment carried out) and ‘mental health ACT assessment’ (which is very specifically an assessment carried out in order to make a decision about compulsory detention in hospital). That’s the key difference and often it needs to be clarified.
That may be enough
‘Oh, is she going to be sectioned?’ may be a response if this has happened before.
‘Well,’ I might say ‘it’s an assessment so we don’t always know the result in advance’
Except some times it is a lot clearer than others.
That would depend on the circumstances and the lead up to the assessment.
We don’t consider Mental Health Act Assessments until all other possibilities have been expended but sometimes it might be someone we don’t know well or something might come up as a part of an assessment that we hadn’t known about in advance or it might just be a wholly inappropriate referral where some of the information given by a panicky care coordinator or family member isn’t quite what we see when we turn up on the doorstep.
Sometimes the prospect of being forcibly admitted to hospital is enough to ‘encourage’ someone who might otherwise be reluctant to engage with services.
If it is a first assessment or someone who hasn’t had any knowledge of the jargon and the way we things might work, I’ll explain in more depth the workings of the Mental Health Act and the bases by which we assess and what the implications are and may be. It depends on level of distress and what some of the precipitating factors might have been and how closely that person was involved – if it’s been possible to have some of these ‘lead-in’ conversations beforehand or not.
So this may have been discussed in great detail before this point arrives – but sometimes it would be someone who had been unknown to our services and with whom we had not had previous contact.
‘So you mean you’re going to section my mother?’
I try to reassure and often will tell the family member not to be frightened of the word itself. ‘Sectioning’. Being admitted to a psychiatric hospital for detention or rather admission, assessment and/or treatment under the Mental Health Act. It is scary. The thought of not being able to leave may be frightening but the stigma attached to ‘being sectioned’ is also frightening.
There are a lot of perceptions of what psychiatric hospitals may be like – and some may be exactly as they are perceived to be but most of the wards I admit to, I know the staff and I know the quality of the nursing care that will be administered. It’s easy to reassure someone of this but it’s hard to break through the preconceptions – understandably.
We also know the stories, we know the general perceptions of what ‘being sectioned’ might mean and the labels that might be attached.
I explain that the word holds all sorts of connotations but sometimes it is about legalities and above all it would be to ensure that we can provide the best care possible for the individual in question.
I explain that we conduct an assessment and that we do this in as humane and thoughtful a way as possible, always respecting the person and not making the situation any more distressing than it need be.
But sometimes it does need to be distressing. Sometimes the thought of ‘sectioning’ brings some of those images – as exist in general media perceptions – of someone being dragged off into the night to a hospital.
And you know, sometimes things do happen that way, I can’t deny it. Well, I don’t work at night as a rule (only if something from the day has dragged on) and there are few times when I’ve personally been involved when the police have had to actually put hands upon someone during the process. It can happen though.
Usually the police are very sensitive. We have some excellent, sensitive and extremely professional police in our borough who are, for the most part, a joy to work with.
Duty of care. It comes back to that. It would be wonderful if everything we did could be done with consent but the nature of the job is that it is not.
‘So you’re going to section XXX?’
Not necessarily, I might respond – we are going to conduct a Mental Health Act Assessment and make a decision as to whether she needs to be admitted to hospital or not.
It sometimes feels like fighting a losing battle.
‘This is the social worker. She sections people’ One of my colleagues introduced me to one of the nursing students.
‘Well, I organise Mental Health Act Assessments where they are needed and make the applications for compulsory admissions’ I try, but that’s seen as me being a bit pedantic. I’m rowing against a tide
‘Yeah, that’s what I meant, she sections people’.
When I was a student, one of my practice teachers was a (as then) ASW. It seemed a faintly mythical task to me – and more than a little scary.
It’s less mythical now of course, as I’m carrying out the same role myself, in a slightly different incarnation. But it’s still scary. There’s still a thought that this assessment, this moment is something that will have a profound impact on the course of this individuals’ life.
‘When I was sectioned.. ‘
And the shame and distress that will cause to everyone involved.
It’s easy to reassure that it is nothing to be ashamed about and that we are ultimately concerned with our duty of care towards the patient and to ensure that the best possible treatment can be administered.
Or sometimes it isn’t as easy to provide that reassurance.
That word again – sectioned.
I see why we were told to try not to use it. It has so much weight to it. So many assumptions and fears attached to it.
But we also need to say it as it is sometimes.
‘Does that mean my mother might be sectioned?’
‘Well, people do refer to it as that sometimes, yes, but it is an assessment’.
And afterwards, when I report back
‘did you section her?’
‘She was admitted under Section 2 of the Mental Health Act’
‘So you sectioned her?’
‘Yes’. Sometimes it is just best to be clear.
You would explain the reasons, the rights and responsibilities of those involved and of the nearest relative. I don’t always get it right. I try to put as much empathy into these conversations as possible.
But sometimes, often, the grief and distress, it cuts like a knife.
Probably not the most in-depth review as I haven’t had a lot of time to process the programme shown on BBC 4 on Wednesday called ‘Sectioned’ as a part of the ‘Out of Mind’ season about mental illness.
The programme’s aim was to allow a greater insight into some (in this case three) patients who had or were being detained in hospital under a compulsory section of the Mental Health Act (known as being ‘sectioned’).
They followed three men – Anthony, Richard and Andrew and looked at the challenges they have and continue to face and the way they have experienced mental health services – particularly and exclusively (because of the nature of the scope of the programme) in-patient services.
Between them, they had experienced a number of hospital admissions and the programme certainly picked up on the cyclical nature of some of the experiences of mental illness. There isn’t necessarily a beginning and an end but more different ways of seeing things and different places along the scale of wellness and illness.
Rather than recount the experiences that were highlighted in the film, I think at least the film succeeded in presenting the stories of three individuals rather than three ‘patients’.
We had an understanding of who the subjects were and the effect that their illnesses had on them and their closest family.
The story was one of experiences rather than processes quite rightly and I think there is scope for programmes such as these to increase appreciation and understanding of the reality of mental health inpatient wards. There was no indication that any kind of support or process existed outside the wards but I suppose that wasn’t the point of the programme. There was a helplessness though that I was almost left with when I wanted to justify a little more hope than was presented but perhaps that wasn’t within the bounds of the programme makers remit.
One of the most striking things was the declaration that hospitalisation is and was crueller than imprisonment. There is no sentence though, just a revolving door and no crime that has been committed to lead to the sentence and the natural cycle of right and wrong.
It was a decent and sympathetic programme covering an aspect of mental health services that is often ignored. I wonder if Janet Street-Porter would benefit from a little time watching programmes such as these and coming to visit a psychiatric ward..
But then, as I explained to my tearful foster child last night, so long away from her family with no idea when or if she might be going home at all, life isn’t about being fair.
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I was wondering how to finish the year off and mark it. So I looked at last year’s posts for inspiration to see how I marked the end of the last year. I ran a couple of posts – one looking back on the year in my first ‘proper’ year of blogging and another post looking at changes that had taken place professionally over the previous year of 2008 and another one looking forward to 2009.
I thought this year, I’d combine them into the same post and then, over the weekend, that will leave me time for the ‘looking forward’ post.
So as far as the blog has gone, I have definitely picked up readers over the past year and thank all of you visiting for that! Without doubt I have had more external distractions this year, with my father’s health fading and his death in August, to starting with the fostering and now, the placement of our third foster child – so I have allowed myself a little more leeway with ‘days off’ than I did in the first year.
I installed a couple of extra widgets to track visitors and Clustrmaps tell me that by far and away most visitors come to me from the UK – unsurprisingly – followed by the United States, then Canada, Australia and then India.
But visitors have called from Libya, Sudan and Moldava – I can’t help wondering if they found what they were looking for!
Unsurprisingly the ‘About me’ and ‘Contact me’ pages are the most popular – probably because they have been constants however the Gerry Robinson posts come up pretty close which, considering the recentness of their posting, shows how many people were affected by the programmes made and wanted to find out more. The effect of the mainstream media is unsurprising and undeniable.
A quick run down on some search terms is always good for a giggle although I can’t beat some of Mental Nurse’s efforts as my most popular search terms have been, after the name of the blog, ‘angry face’, ‘general social care council’ and ‘good mental health’. Fairly expected, I think.
As for the next year, I definitely intend to read and discover more blogs, even if it means cutting down my own output a little as that’s an area that I haven’t concentrated on as much this year. Ideally, I’d like to produce better quality postings, less frequently, if necessary but retain the mix between commentary on social work, mental health and anecdotes from my working life with the occasional foray into personal thoughts.
And professionally, looking at 2008, I was reflecting on the changes to the Mental Health Act and the introduction of the Deprivation of Liberties Safeguards.
This year, it seems to have been about the Social Work Taskforce and coming in right at the end, the New Horizons paper on the future of Mental Health services in the UK. I expect both of these documents to have a major impact on the next year, at least, in a very real and immediate way. We have already had documents sent round about changes planned across the Trust as a result of the New Horizons proposals. I expect many changes before the year is out.
As for the Taskforce report, my expectations are that the impetus to change will come more slowly but I am comforted by the results published and am hopeful that there will be a blossoming in the development of social work in the UK. Ever hopeful, of course but as I was saying to a colleague just yesterday, whether you are an optimist or a pessimist, is unlikely to change the outcome, but if you are optimistic, you might have a more enjoyable experience along the way!
We have a general election coming this year – and a likely change of government, with different agendas and priorities, all in the climate of public sector cuts which are already affecting services. Interesting times.
The personal hopes for last year involved me aiming to start the Practice Education branch of my Higher Specialist Award and indeed, I have started that now. I have initiated my first couple of Individual budgets and although I retain a healthy dose of scepticism, I am committed to making sure all the concerns I have are raised and in order to do so I have to embrace the changes so that I can speak from a position of knowledge rather than stand on the sidelines and complain about changes in general.
I have noticed in myself that I have become more confident in my work and practice. I think that is something that grows incrementally each year but this year I felt more confident. I think that is partly due to the management and colleagues around me and the ethos that exists in my team which is very supportive.
I also resolved to try and become more active in both UNISON and BASW. While UNISON has been jettisoned a little bit, I have been more involved in a number of ways with BASW and have enjoyed the process of becoming more engaged with the profession on a wider basis than my office or my local authority. It has been heartening to see BASW become more vocal and confident and I am interested to see where that path lies.
I know the decade ends in 2011, but for my purposes, I’ll use this as a chance to look back too – although briefly – because in 2000, I qualified as a social worker. I find myself 10 years down the line. Partly I’m surprised I lasted this long – many of my colleagues on that MA (as it was then!) course that I attended have moved into different careers or away from front line practice.
I have worked in Community Care Teams, moving into Mental Health in 2006, nonewithstanding the ‘lost’ years I spent in Italy doing nothing related to social work but which remain possibly the best thing I ever did and instilled a wealth of experiences that have shaped who and where I am now. Professionally, I worked though more statutory focus on carers and direct payments through to the initiation of individual budgets and the personalisation agenda. The Delayed Discharge Act which saw local authorities being charged for hospital stays if they were unable to facilitate discharges and what seems sometimes like over speedy discharges from hospital. I wonder how far that line will run. It seems that all policies are pointing to more care in the home and away from institutions.
I also trained as one of the last ASWs (approved social workers) – in fact, I was the last ASW warranted in my borough – in July 2008 before moving straight into the ASW to AMHP (approved mental health professional) conversion training.
Without doubt that training has been the most significant to my professional development over the last decade. Seeing the beginning of the DoLs (Deprivation of Liberty Safeguards) process and the mess that seems to exist within what looks like frankly sloppy legislation and protocols and being able to recognise it as sloppy, will no doubt be one of the key parts of the legacies the decade leaves in my service area. The scope of the Mental Capacity Act still has a lot to encompass and needs a lot of padding out – probably by case law.
It’s easier to look forward one year than ten so I’ll duck out of decade predications until next year.. but as for the coming year, I’ll put something together over the next few days.
For now, there’s still another working day left of the year.. but Happy New Year to all and thanks again for visiting.
I’m coming back to Best Interests Assessments and DoLs for a while now so excuse my indulgence but it is something that has and is creeping back into my workload after a few ‘dormant’ months and a part of the reason has been the impact of the ‘GJ’ judgement which has been winging it’s way around various communication channels in our Trust.
I found a good summary of the GJ v Foundation Trust, PCT (Primary Care Trust) and Secretary of State for Health case in Family Law Week.
It clarifies a lot of the questions that existed about the ‘eligibility’ assessment part of procedure to determine the authorisation or otherwise of a ‘deprivation of liberty’ under the framework of the Mental Capacity Act as opposed to the Mental Health Act.
When assessing people who are being deprived of their liberty and who lack capacity, in a hospital setting, the eligibility assessment has always been crucial. The eligibility assessment disbars the authorisation if the patient would otherwise meet the criteria of an assessment under the Mental Health Act.
I am aware that this may seem a little dry to those coming in from the ‘outside’ but it is absolutely fundamental to the legislation and the legislative tools that we engage with.
The situation of GJ, as highlighted in the case law, relates to himself, as a 65 year old man suffering from Korsakoff’s syndrome and vascular dementia as well as diabetes. His partner had assisted him in managing his diabetes prior to her death however following this, he had suffered from two hypoglycaemic attacks with obvious consequences for his physical health.
The discussion in the judgement published by the Court seems to centre around the question as to whether the treatment in hospital is on physical health grounds in which case, it would seem that a DoLs authorisation may be appropriate however if there is any part of the treatment process which relates to a mental health need, then GJ would move into the ‘ineligible’
The judgement summarises that there are two strands to this case – namely whether GJ is being detained and treated in hospital and thus being deprived of his liberty on the basis of his physical treatment regime and the only reason for this detention was on the basis of his ‘package of physical treatment’. In which case, he would not be a ‘mental health patient’ and an authorisation could be granted to deprive him of his liberty to receive this treatment under the Mental Capacity Act.
However, if the mental disorder existing were to be treated in a hospital setting, that seems that the eligibility requirement for the Mental Capacity Act would be ‘failed’ and the Mental Health Act assumes it’s primacy in this situation.
The other crucial point that can be gleaned from the judgement is as follows
58. In my judgment, the MHA 1983 has primacy in the sense that the relevant decision makers under both the MHA 1983 and the MCA should approach the questions they have to answer relating to the application of the MHA 1983 on the basis of an assumption that an alternative solution is not available under the MCA.
59. As appears later, in my view this does not mean that the two regimes are necessarily always mutually exclusive. But it does mean, as mentioned earlier, that it is not lawful for the medical practitioners referred to in ss.2 and 3 of the MHA 1983, decision makers under the MCA, treating doctors, social workers or anyone else to proceed on the basis that they can pick and choose between the two statutory regimes as they think fit having regard to general considerations (e.g. the preservation or promotion of a therapeutic relationship with P) that they consider render one regime preferable to the other in the circumstances of the given case.
So the Deprivation of Liberty Safeguards cannot be used as an alternative to use of the Mental Health Act as the eligibility criteria still need to be met in order for the assessments to continue. I’ve underlined for greater emphasis as much for my own benefit as anyone elses’ as I know personally of consultants who have favoured referring patients for the DoLs framework rather than using the Mental Health Act as it seems ‘least restrictive’ (an argument that doesn’t really exist in my view as the effect, namely someone being in hospital against their volition is the same in both regimes and in fact, there is a much more robust appeals procedure available under the Mental Health Act).
I’m sure there are many more qualified to sift through the case law which is coming from the Court of Protection, than I but it is a relevant judgement that has a significant impact on my work as a Best Interests Assessor and as an AMHP, eligibility assessor under the DoLs framework.
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Tags: approved mental health professional, Best Interests Assessor, bia, Case law, court of protection case law, deprivation of liberty safeguards, dols, gj judgement, gj v foundation trust, health, mental health act 1983, mental capacity act, Mental Capacity Act 2005, Mental disorder, mental health, mental health act, mental health act primacy, mental health act v mental capacity act