February 2010 - Posts
another week has gone by in my busy working life.
we seem to have had a few referrals recently in the Community mental health team (i have two part time jobs one in the cmht and one in early intervention) for people with substance misuse issues and mental health problems such as anxiety and depression. my initial reaction is that just because these people have substance misuse issues they should not be excluded from our service however there are some in the team that feel that unless these people sort out their substance misuse then we cannot sort out their mental health problems, the service user i am thinking of has a problem with alcohol and is inebriated for the majority of their waking day, she is also neglecting herself eating very little and living in a house with no heating or electric due to spending all her money on alcohol, and although i do understand that its hard to do any structured therapeutic work with someone who has issues with alcohol there is the basic care coordination that may make things easier for them, and i do understand that alcohol is a depressant but i bet that's not why they started drinking rather they started drinking as it made them feel better, albeit short term until the hangover kicks in.
the dual diagnosis guidance from the Department of Health states that people with a dual diagnosis should be cared for in mental health services or at the least joint worked within the two teams - mental health and substance misue, and i think to refuse people a service because they drink seems harsh. is it okay not to offer our service because they drink too much? i know our local drug and alcohol agency rely on people accessing their service themselves, and i understand the reason for this - the stages of change and motivation i.e someone needs to be motivated to change to change but that leaves lots of people with no services, no service from substance misuse agency due to the lack of motivation and no help from the mental health services due to their drinkning which means that people will fall through the net.
when i decided to get into social work one of the reasons was i wanted to prevent people falling through the net between services, it does not feel ethical to me to let someone drink themselves to death without giving it a continued and sustained effort to help them but then i suppose there is the issue of resources and time which are both limited in a busy team. i spoke with a collegue about this last week and she said that even if it was the drinking that came first and the mental health issues followed how are they going to be able to address the issues of substance misue when they feel so depressed and i agree with her.
however it is still a contentious issue in my team and will probably be so until someone issues clear cuidance for how we work with these people until then i will keep fighting their corner. what do other people do and what do other people think?
we got a memo sent round our office last week, would all staff clearly wear the ID badges at all times, well i was not happy, and i moaned and moaned and was then told to just get on with it. my issue you see is that the service users we work with would like a bit of privacy and probably dont want their neighbours / friends/ joe blogs in the street to know that they have a mental health social worker ( or in the case of my colleagues a psychiatric nurse) visiting them at home or taking them into town for a coffee and if we have to wear our badges then people can see that the person we are with are not actually our friends or relatives but we are paid to be with them, how humiliating! i thought that one of the things about anti oppressive practice is being aware of our power and the effect it has on our service users and there is nothing like power than wearing our profession on a badge round our necks or pinned to our jumpers.
its like knocking on doors with the big black diary in our hands or in the case of our MH nurses carrying the black briefcase full of depot medication knocking on the door, where does social inclusion feature in that?
anyway i have a solution wear a long jumper and pin the badge to the waistline of my trousers so that i can cunningly cover it up then when i go onto the wards or into NHS premises i can tuck said jumper in (and look a bit of a dork!) so that those who must be obeyed can see i am flashing my status.
its not all bad at our trust though they have broken the links with the drug companies, no more reps coming round giving us free lunches, pens, badges t-shirts t-towels (the last three were lies) so we listen to their latest speil about how superior their drugs are in fighting the menace of mental health, i was so pleased and so were any of the people i work with although there were a few that were dissapointed there was no more free lunches, for me its just never felt ethically sound to take backhanders from the multi nationals.
today was my first experience of a Mental Health Tribunal, it was an anxiety provoking experience for me and so i can only imagine what it must be like for service users.
i was there with two hats on, one as a social worker who prepared a social circumstances report and the other as the servce users care coordinator.
i will begin with the social circumstances report, initially i wrote this at the end of the last year, the service user concerned is subject to a supervised community treatment order and at the end of the summer she became unwell and was recalled to hospital as a condition of the order. it was then revoked and turned back to the original section 3, as it was revoked the rules dictate that the case then automatically gets sent to the tribunal, the tribunal was then all set to go, i wrote the report and then for circumstances beyond anybodies control it could not go ahead. the service user was then discharged and the CTO was reinstated however as the rules state the tribunal still needed to go ahead and i had to rewrite the report as the service user was no longer an inpatient and back in the community doing really well. the report felt harder to write as the service user was in the community, we have a proforma in our agency that we can use for the report but that is as an inpatient so i had to adapt so it was suitable for the community. writing the report which was five pages long reminded me why i wrote so many essays and why it is so important that we as social workers can write at degree level with good grammar and spelling, it had to be a professional piece of work as it was scrutinized by the panel.
the actual tribunal was a strange affair, its there to protect the rights of the service user however it was an hour and a half of fairly intense conversation and at times the service user was discussed like she was not in the room and that she was deficit in some way, there was a lot of medical langugae and labelling going on, the service user did have their say however when asked questions such as do you think the support you get from your care coordinator is satisfactory when i am sat in the room does not really give them the chance to say no, i said this afterwards to the solicitor but he said that people do say no sometimes but i still think that service users can get worried that if they say the wrong thing they may affect the support they recive in some way. i have read research concerning how service users feel their views are interpreted and some believe that if they complain then services ,may be removed or they wont be believed as they have a mental illness.
the tribunal for people who don't know consists of a tribunal judge, a tribunal psychiatrist and a lay person. as it was in the community for a CTO there was also myself who was the author of the social circumstances report, the RMO which i think stands for registered medical officer, the service user and their solicitor, the RMO also submitted a report and the solictor who had met with the service user previously spoke on their behalf. i was hoping it would be an empowering process for the service user, protecting their rights but it did not feel like that and when i asked the service user they said they found it disempowering and depressing listening to people talk about her like she was unable to make descions for hierself and reminding her that she was mentally unwell.
i am sat here wondering if i would do anything different next time and at the moment i cannot, i am not saying my performance was faultless but it is a fairly perscriptive process and there is not much room for error.
i notice the DSM-V is on its way, they have a website where if you log in you are allowed to comment on their proposed revisions, DSM-V.org,
i work in an Early Intervention in Psychosis Team so am always interested in things concerning psychosis.The DSM-V is floating an idea that 'at risk of psychosis syndrome' should be included, either in the main book or as an appendix for future research. it made me quite surprised that what they had included as the symptoms of at risk of psychosis is what we call someone experiencing a psychosis. not at risk but actually experiencing it. so i pondered whether we label the experience too early and what the positives of labeling is anyhow apart from the fact people are often relieved that what they are experiencing has a name and other people with the same label can get mutual support when they all have the same label, it also makes it easy for people to say a one or two word name rather than a speech of symptoms. SO do we label psychosis too early i'm not sure but the DSM-V is not going to change that but it may mean people are diagnosed earlier and if that is the case we can collaboratively do some great work on learning how to cope with their experinces and trying to stop them from being distressing, whether this is through pychotheraphy, psychology, CBT, art therapy, medication, family work and old fashioned engagement.
The DSM-V has recognised that early intervention leads to better outcomes however it does not say what early intervention is, I wonder whether if it is listed in the book, some doctors may prescribe anti-psychotics even earlier than they do at the moment, there has been a few stories come out of the American press regarding young children and psychosis, do you remember Jani the 7 year old schizophrenic (sic) and Rebecca Riley the four year old girl with a diagnosis of bipolar both which i found quite disturbing, the medicalisation of childhood. Children and young people dont need powerful medication as a first response they need time with someone to help them understand what is happening and why and ways to manage what can be distressing experiences, as we know sometimes the medication can have side effects that can be hard to handle too.
anyway it made me wonder what the point of the DSM-v is, is it a
diagnostic manual or is it like the phone book of mental disorders?
i am currently working with someone who has english as a third language, and although he can speak English well i felt it was important to find some information on hearing voices in his first language, my first port of call was my manager who i asked where i could get a translator, i was a bit perturbed when he told me to explore the options on the internet, well i was furious and just thought it was a money saving oppurtunity and how could i offer an equitable service to all if i could n't give information to people in their mother tongue! anyhow i found this brilliant thing on Google. you just type in the address link or even upload documents and it translates into your desired language in a millisecond ( slight exageration there but you can tell it got me excited!) so i thought i would share this with anyone who may need this brilliant resource in the future,
I work in an Early Intervention in Psychosis team so I work with some quite poorly people, since i started in June i have heard the word insight bandied about a lot and it has got me thinking what if the people who are deemed to have no insight are in fact not unwell just see the world differently to us and why should that be such an issue that they need to be medicated or locked away. I can understand when people are risky to themselves or to others but just for believing that God is sending them messages through a hamster ( like one young man i am working with at the moment) or that they have to travel 30 minutes on a train to read a bible in a phone box ( which is what another young person does as he belives it his mission) then what is the real problem with that?
i guess really its about distress, does the person concerned feel distressed by their experinces and is it puitting them or others in danger? as a social worker in a mental health team i like to think i have an alternative view to the medical model but it can be hard being the only social worker in a team of medical colleagues and even more so if those colleagues are old school and i am Newly Qulalified and finding my feet, as my NQSW mentor said the other day i need to develop my quality of arseiness! i guess you may be reading this and thinking maybe i am a bit of a wet blanket but i do challenge my medical collegues and i have prevented some service users from being admitted to a locked ward and had them admitted to a more informal ward in a community hospital, i have also persuaded the psychiatrist not to prescribe hideous haliperidol and try something more friendly like aripiprizole, but there lies my problem i dont completely disagree i just try and look at a soloution that is less restrictive but i guess thats what you have to do in a multi disciplinary team not completely go against your colleagues but look for compromises. The least restrictive approach is always at the back of my mind and is my mental health mantra.