What does a Mental Health Social Worker do?

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 Programme 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!

Between the NHS and the Local Authority – On Being Seconded

I’ve been a local government employee for a good number of years but however much I try to ensure that I am fully linked into the policies that trickle down to us via my own employing council, I can’t help but feel an increasingly sense of separation on the basis of my ‘secondment’. Don’t get me wrong, I think the advantages of the secondment outweigh the negatives but it’s something I tend to just take for granted.

It isn’t uncommon for mental health social workers to be seconded to mental health trusts. It is the case in most of the mental health teams I know. While my colleagues whom I sit alongside are employed on NHS contracts, only the social workers in the team are local authority employees.

The background to this is mostly historical. Before community mental health teams were interdisciplinary in the way they are now, social workers within the local authority worked generically and so when these new teams emerged, some of those generic social workers were moved out and seconded into the new teams in the NHS. Legally, there was also a provision in the 1983 Mental Health Act that specified that Approved Social Workers should be employed by the responsible local authority.  A change in the legislation with the passage of the 2007 amendments to the 1983 Mental Health Act mean that the employment is no longer specified and there are some noises about some of the social workers being employed directly by the NHS but I feel relatively confident in saying that my position of being seconded to work in the NHS by the local authority is likely to be the majority position for Mental Health Social Workers in England at the moment.

I moved into this team  from a local authority social work team and without doubt there is an increased feeling of isolation and detachment from our local authority employers when I compare the experience to that when I worked in the local LA office.

On a very basic level, we are frozen out of the intranet and the local authority IT system. It wasn’t always like this and isn’t supposed to be like this but increased security both on the Local Authority IT systems and the NHS systems mean it is impossible to run both networks on the same physical PCs.  Whisper it quietly but I haven’t checked my local authority email address for about three months and only get around to it when I visit other offices and can borrow someone else’s PC that is ‘on the network’.

The difficulty in this is that some people in our communication department, despise being told again and again and again, refuse to believe us and persist in sending all relevant information to our local authority email addresses.

Some people in other departments repeatedly try to contact me via the LA email address and although I have an ‘out of office’ response on it, I always find things that I should have seen much earlier when I check it. I know, it’s my own fault but they don’t make things easy for us!

It also means the ‘wonderfully efficient’ e-tools that the local authority has in place on its intranet to do all your appraisals online and to book annual leave and training online remain barren and unused and we are using scraps of paper to log our annual leave because HR wants to charge us for paper versions of the old ‘cardboard ‘real’ Annual Leave cards’.

It also explains why, apart from safeguarding training, I receive almost all my annual quota of training from the NHS Trust rather than accessing the local authority training schedules.

Recently, I did find myself in a meeting over in the local authority offices and  I was actually staggered by the amount of policies I hadn’t been aware of, training I haven’t heard of and ways of working that had completely passed me by.  Of course, none of it makes a massive difference to practice (which makes you wonder about the people who sit in offices and write reams of policies)  but sometimes you feel almost as if you have a duel identity working in an NHS team as a local authority employee with neither ‘employer’ wanting to take overall responsibility. Mind, I’m still a bit bitter about the lack of our involvement in the development of personal budgets. I genuinely believe we could have created a far better system if we had been consulted about the way that process had been rolled out and piloted.

But the positives outweigh the negatives. Apart from the annoyances that emerge when trying to claim any kind of expenses back for travelling which involve begging a ‘friendly’ local authority team to let us please use their budget for our ‘permit to travel’. Fortunately having previously worked in the social services office, I have some contacts to lean on at the requisite moments but it is not something that is made particularly easy for us.

The main positive is the sense of independence for a start. We are slightly detached from the rest of the CMHT having different employers and can sometimes take a step back. Personally, I think it allows a greater freedom to challenge ‘from the outside’ as one thing that can definitely be said about the NHS is that it is a hierarchical organisation. By remaining slightly outside as seconded employees and being ‘representatives’ of the local authority within CMHTs gives it a slightly different hue and sphere of influence.  The role of the Mental Health Social Worker in a team has to be about advocacy and promoting involvement and bringing the importance of social issues into the scene when looking at helping someone holistically.

Terms and conditions are generally (although this is arguable) better in the local authorities. None of the social workers want to switch over to NHS contracts (because yes, it has been discussed many times and is something that seems to be perpetually ‘in the pipeline’ since the change in the 1983 Mental Health Act).

I think the feeling of difference is remarkably important and it gives the local authority a physical presence in the team which is particularly important as care management and support planning is a massive part of our role in older adults services. The introduction of personal budgets to all our service users has meant that more information and documentation is channelled between the teams but I can’t help the nagging feeling that we are sometimes the  ‘forgotten’ employees. This is not always a bad thing.

As well as the intranet and the lovely sparkly new HR systems that we can’t use, on a far more fundamental and basic level, we can’t use any of the local authority databases. Their attempts to move everyone to paperless working mean many battles trying to explain to whichever service it is that we can’t get onto the intranet to make referrals online seems to be a constant.

In my dream world, the local authority would issue some kind of communal email to everyone in the council telling them that not everyone who works for the council can actually access the intranet. I think that would come as news to them on account of the amount of times I’ve tried explaining this to baffled looks of astonishment.

But generally, I’m happy where I am.  Taking a step back and looking at the situation in the broader context, I think I have and am continuing to learn incredibly useful lessons about the ways that organisations develop and grow and work or don’t work.

Sometimes there are frustrations but if everything worked perfectly, it would just be more boring and standing between both the Local Authority and the NHS allows for a more critical reflection of the ways that both operate and are managed in a way that I couldn’t have if I were entirely placed in either one or the other.

Press, Perception and the Court of Protection

Having had to study the Mental Capacity Act in fairly great detail, I often have to turn to judgements made by the Court of Protection to extend my general legislative knowledge.

The Court of Protection has a number of functions that can get easily interwoven but generally, it makes judgements about issues of capacity.

It’s always interesting to me how the press report Court of Protection judgements as in general the court sits in private . It isn’t thought of very highly by the press – probably for the very reason that many of the cases take place behind closed doors – which is particularly unusual for a court in the UK. Indeed, it’s traditional journalistic byline seems to be ‘the-secretive-court-of-protection’.

There was a case this week which was heard which involved a pregnant woman with learning disabilities and a decision which was to be made as to whether she should be subjected to a sterilisation following the imminent birth of her child. It is very emotive and difficult as an ethical subject.

The Court decided, unusually, to open up the case to the media with the usual and understandable constraints of anonymising the parties.

What I found interesting was a comparison of reporting about the story before the case was heard and afterwards.

The Daily Mail is a case in point. On Tuesday Morning it published this piece.

They quote a spokesperson for Mencap

David Congdon, of disability charity Mencap, urged the court to ‘tread very carefully.’ He said: ‘It is a gross invasion of someone’s basic rights unless there are clear medical grounds and there do not appear to be in this case.

‘Using sterilisation as a form of contraception is totally unacceptable.

‘Years ago there were lots of cases like this but we hear of very few these days.’

Applications to sterilise women with learning difficulties can come from local authorities and do not require the backing of their families, he said.

‘The family’s position in these issues is not that great, because the person is an adult,’ he added.

‘They have to be consulted, but the application may have been made by social services.’

I can’t say I disagree with Congdon, it is a massive potential infringement of human rights to forcibly sterilise anyone but the weighting in the quote implies that the court disregards the family and it is a cunning and devious decision made by social services. Regardless of the fact that it is a medical procedure and any application would have to be made by the Trust employing the medics who would be responsible for carrying out the task.

The Telegraph use the same quote. As does the Independent which adds

Since the Independent’s battle to open up the Court of Protection, the paper has received numerous calls from people who allege that local authorities have been using the automatic secrecy governing the Court of Protection to severely restrict access to their loved ones. Because the hearings are largely held in private and no court listings are generally published earlier than the afternoon before hearings, it remains difficult to investigate and analyse such allegations.

You see, it’s easy to make one-sided complaints about a Court or a local authority when you only have a part of the story.

It’s easy to accuse ‘social services’ of being overbearing and evil when they are not able to construct any kind of counter-argument for the sake of the service users they represent. I say this having been involved personally in a case which could have been presented in a very one-sided way and would have been prime meat for the front cover of The Daily Mail – however the background of abuse within the family meant that what might have appeared to be callous actions had to be taken. We could never disclose that so would never have been able to defend ourselves.

But back to the secretive Court of Protection. The judgement or lack of it came yesterday as more information about the case was revealed.

It so happens that the woman’s mother was in favour of the sterilisation of her daughter. This is not a situation where the family have been side-lined by any means.

As the Mail put it yesterday

The woman, known only as Mrs P, broke down as she explained the drastic procedure was the only way to spare her 21-year-old daughter the heartache of having further children and being forced to give them up for adoption.

The daughter, known as P, already has one young son and is due to give birth to a girl today by caesarean section.

She was described as ‘sexually healthy and active’ but unable either to exercise restraint, or fully to comprehend the consequences of her behaviour.

Her mother told the Court of Protection that while her family would support these two children, they could not cope with any more.

She said: ‘I want the best for my daughter. We want to keep the children together as a family unit. But obviously we can’t keep on supporting more and more children.

Not really the evil social services taking action behind the backs of families that might have been implied the day earlier from the reporting.

It is an incredibly difficult decision to be made and as it happened, no decision and therefore no sterilisation order was made. The judge, ordered that at present there was no sufficient evidence to meet the criteria for such a drastic action under the Mental Capacity Act and while the best time to perform the sterilisation would have been at the time of the caesarean (which I believe was to take place this week), further hearings will happen over the next few months before a final decision can be made.

Clearly it is not a body that makes heartless and unconsidered judgements for the sake of it and loathe though I am to wander into the comment sections of Daily Mail stories, the difference between tone in the first story where the situation had been set up and has comments such as

‘All those in favor please show us your Nazi membership card as this is exactly what they did, So be very very carefull, many alive now do not understand the implications of what is potentialy a dangerous and devastating and far reaching precedent bought on by these council jobsworths. ‘

And

‘OMG, my blood is boiling reading this tragic story. What right do the council have to do this? How severe are this woman’s learning difficulties? Why not give her a contraceptive jab every 6 months, given at home if need be? Are social services and a representative of the secretive family court going to be present at the birth of the baby, whisk the baby away as soon as it is born and put up for adoption? If this is given the go ahead by the judge and forced sterilisation takes place, this is just the start. We will have crossed a line and the ‘Brave New World’ will begin. ‘

I know the Daily Mail comment section is not the place to look for rational argument and debate but we get a feel of the general perception that this is somehow a ‘council decision’.

After the information is shared in the second article, the tone of the comments change to

It’s sad but i have to agree with the mother. I think she has a very valid point. She will be looking after the children and it will break the WHOLE family’s heart should they have to give up any children for adoption. Also what happens if she falls pregnant every year till she can’t have any more children. The daughter clearly does not understand the situation because of her disability.

And

Unfortunately due to the Human Rights Act, this mother’s desperate plea will be ignored despite the emotional, psychological and physical turmoil this young girl will go through again and the stress and pain for her family. Very sad situation for everybody involved including the unborn baby.

Please don’t assume that I am ‘in favour’ of the sterilisation as a matter of course. I’m not but I do think the decision is absolutely taking place in the right arena where the considerations of P and her family need to be wholly taken into account under the law.

It’s just easy to see, in this case, how easy public perception and tone can be altered by reporting styles and language.

The Joy of Targets

We operate to a system of targets. That should be no great surprise. It is how ‘value’ is determined and efficiency is maintained. Social Work is, for the most part in the UK, funded from the public purse and it’s quite right that we should be subject to a checking and controlling system than ensures we give the taxpayers value for money.

But (you could see the ‘but’ coming, I suspect) the types of data that we are expected to collect can provide a false sense of security in the systems. Some of this has clicked with the press over the weekend. Targets were met in Haringey. That does not mean a quality of service is maintained.

image tj scenes at flickr

I’m not against all targets, by the way. One which I think has improved the service is the one which is based on time from referral to contact. It means that noone can sit on a ‘waiting list’ not knowing what is happening to them. Even if it is just someone phoning to acknowledge receipt and give a contact telephone number until an assessment has been completed, at least that is better than hearing nothing.

Some though, are less than logical. There is a target relating to how many cases we close. By the way, I was taught never to refer to cases as case  but as people. So while I’m writing that in my head, I’m thinking ‘people’ but it just doesn’t seem to flow as well!

Back to the case-closing (I couldn’t really write people-closing..). To me, it is one of the more difficult targets to get my head around. I’ll close when I need to – not based on targets or pressure. It’s probably one of the more damaging targets, I think.

Then we have targets set by the NHS Trust and targets set by the Local Authority. The Trust, for example, sets guidance that we should each care coordinate 25 people and that we should register at least five ‘contacts’ per week. The five contacts is usually very easily achieved. Sometimes I might do that in a day.

Their views of contacts aren’t necessarily my view of contacts though. Going to visit someone in their home, ok, that’s an easy one, of course that’s a contact.

Going to visit someone when they are at home and they aren’t in/don’t answer the door. That’s also a contact (actually that doesn’t happen to me too much).

Visiting a carer or any kind of carer support. That’s not a contact.

A telephone call that is over 10 minutes and has some kind of therapeutic value (self-judged) is a contact.

The team I recently left was the worse in the Trust for the contacts. Or the worst at actually entering them on the database……

I think the older adults teams suffer slightly by having the same targets as the other CMHTs though. Our care coordination requires a lot more care management (putting together and monitoring care packages as older people tend to be more likely to need physical help) and our service users never come to our office to see us.

We are out and about a lot  more. I think, although this is gut instinct, that there is a lot more carer support work that possibly goes on in our teams. I know there are some weeks that I have done nothing else.

Then we have the Local Authority targets. I used to be really hot on these when I worked in a local authority office. Now.. possibly not so much. It is to make sure that reviews are regular and timely – but they also include things like monitoring work status without providing any way to put ‘retired’ on the forms they must have spent hours devising.

We have targets for carers support packages (actually providing services), direct payments and carers assessments. Apart from Direct Payments where the only situation where I was going to do this was in progress and was never seen through to completion due to other factors that changed the situation while I was working with it, I’ve been pretty good at the carers assessments and the carers services.

Not bad, actually, those targets. They remind us of the job we need to be doing.

But then there is the target that really rankles me. We have a target amount of Safeguarding Adult Investigations to complete. OK, it isn’t a high target but shouldn’t some things just be. . er.. done on the basis on which they are needed. Luckily, no manager I have ever worked with has ever done anything but be baffled by this as a target. It happens or it doesn’t.

The need to create a tick-box culture does more than anything else to remove the professionalism required.

Targets aren’t going anywhere. Some can encourage good working practice, even, but when they are imposed on a draconian basis, there is a danger that they will attract shoddy and half-hearted work on the basis of ‘completing a target’ or ticking a box. That is the real danger. So by all means, set targets – but make them realistic and relevant to individual services. What works for one agency or service may not work for another.