‘The balance between risks and rights is key to forensic social work’

Most of the people on social worker Mike Wheeler’s caseload have committed offences of varying severity while they were mentally unwell. All are detained under the Mental Health Act. Prior to arriving at Mike’s service, several will have spent time, often years, in prison or high security mental health units, such as Broadmoor hospital. Mike’s job is to – hopefully – help them recover and move through the hospital system back into the community.

Mike is the team manager at South West London and St George’s NHS trust’s forensic mental health service. Alongside inpatient wards (the service has 60 low and medium secure beds), the service also has a medium secure ‘rehabilitation flat’ for people to test out semi-independent living. When people are discharged into the community, the trust provides ongoing support through its forensic outreach service.

A ‘guide for referrers’ for the service highlights the complexity of this area of mental health work. It shows that patients arriving at the service will typically have three traits: a diagnosis of a severe and enduring mental illness; complex needs, often including challenging behaviour and/or substance misuse; and a serious and ongoing risk of violence and injury to themselves or others and/or sexually inappropriate behaviour.

‘People can feel cut off from society’

“We’re a forensic service so risk permeates the whole arena. We have a dual responsibility – first to the patient and supporting them to get better and secondly the protection of society and other people,” Mike says.

While being honest about the risk, Mike also says it’s important to realise the additional issues that forensic patients face.

“People who come into forensic care are very stigmatised – one because they’re mentally unwell and two because they’ve committed crimes that may have got media attention. They can find themselves very isolated and cut off from society,” he says.

“We want them to feel included. As social workers we want to uphold their human rights. We want to help them move through hospital. It’s about valuing people – looking at the whole person not just something [the offence] that may have happened when they were very unwell.”

‘You can’t impose a care plan’

Mike’s work is largely focused on supporting people’s recovery to help them feel able to leave the hospital system. When someone arrives at the service, he starts work with them on a pathways plan. The ultimate goal – and, Mike points out, the process can take years with such a complex client group – will be to help the person reintegrate to life in the community.

Along the way he’ll look to identify local resources, whether it be voluntary sector projects, social care support or services within the trust, that could help the person meet their recovery goals. When someone feels ready, the team might arrange for them to have leave from the ward to try out community projects (“It might be courses, training, running, decorating, DJing – you name it and we’ll try to support it, shopping – people might not know how to shop. We work with people to do things at their pace”).

A key part of the role, Mike says, is getting to know each person in-depth and being available for them to discuss any issues. He runs regular clinics on the wards and is keen that any recovery plans are co-produced, not imposed by professionals.

“If you impose your own plan that someone isn’t signed up to, it won’t work. We try to look at your interests, your hopes, your own goals for the future. What do you want when you leave hospital? How can we help you get there and help it feel manageable? We acknowledge, first of all, that this is a big step. Some people have been in hospital a very long time,” he says.

The time someone spends with the forensic service varies. Someone who is on a low secure unit might stay on average for a year and a half or two years before they are ready to transfer to the community, Mike says. For patients on medium secure units, stays can be far longer, and relapses can force people to return to high secure hospitals. Plus, even if someone spends a year with Mike’s team, they may have arrived at this service after decades in other parts of the hospital system.

“I recently supported someone back into the community who had been in various hospitals for over 30 years,” says Mike.

“That was hugely satisfying. It involved so much preparatory work in terms of managing anxieties, putting in structures, some visits to hostels to see how he felt about them, working with the occupational therapist to discuss how he wanted to spend his time, what he wanted to be doing. We wanted to get it right for him.”

Promoting social work’s professional identity

Mike’s team is multidisciplinary. Social workers work side-by-side with medics, nurses, occupational therapists and others. He says that working with other professions brings plenty of benefits but, as a manager and social worker, he is also keen to maintain social work’s unique professional identity alongside the positives of integrated working.

Social workers, Mike says, bring a vital social perspective to a mental health system that is dominated by medical models of care. He points to Mental Health Act tribunal reports, where social workers will often take detailed social histories and sometimes challenge the views of psychiatrists.

“Teamwork and partnerships are all about developing a really good relationship with colleagues within the multidisciplinary team, but sometimes we will have differing views to our psychiatric and nursing colleagues. We expect our social workers to be confident, assertive and human-rights orientated,” he says.

Mike says he is continually reflecting on how to retain social work values in the service. It helps that South West London and St George’s mental health trust has strong social work leadership, certainly compared to many NHS organisations.

Ruth Allen, chair of The College of Social Work’s mental health faculty and the author of a report advocating a prominent role for social work in the future of mental health services, is the trust’s director of social work (few NHS trusts have such senior social work representation). The trust has also held its 10^th annual social work conference this year. Some other mental health trusts have only just held their first, while others don’t have one at all. The trust’s social workers also receive supervision from social workers – a situation that, while it sounds straightforward, isn’t in place in many mental health trusts.

“I think, when we are doing integration right, what we bring as social workers is our value base of social justice, social inclusion, rights,” says Mike.

“I’m trying to develop the social work opportunities. We have dedicated, committed social workers but I want to keep on thinking about how we can help them to keep developing their skills. Some people like practice teaching, some like AMHP work, some people are really good clinically. If we can get the best of those, the cross fertilisation of those perspectives, it can really benefit the people who use our services. Ultimately, I want us to be providing excellent care.”