By a social worker and Approved Mental Health Professional
I often feel a bit stupid saying it but when you work in mental health crisis teams or as an Approved Mental Health Professional (AMHP) you have to make life or death decisions.
I remember being on call out-of-hours and getting a phone call through our crisis line. All I could hear was the wind howling and lots of cars. Before I had a chance to talk to the person on the other end the phone went dead. Your instinct tells you they might be on a bridge about to jump and you have to make a call on how to respond, and quickly, to try and ensure their safety.
Risk is part of this work
That is an extreme example but it is not an uncommon one. Risk is part of this area of work. It comes with the territory. But my worry is that the level of support on offer to staff to try and manage those risks safely – in the community or through hospital admissions – and help make those very, very tough calls about the best way to support someone who is in the middle of a crisis, is insufficient and getting worse.
I’ll give you an example. In our local crisis team there is often half the ‘optimum’ number of staff needed for the caseload. The situation has worsened as people go off on sick leave, often for stress. When you’re so short-staffed you end up divvying up the work between the team and the thinking starts: ‘Who can we afford to not see today?’. That must be a horrendous call to have to make.
Those services are supposed to be offering intensive home-based support but when there simply aren’t enough staff to do it, that kind of decision has to be made. It means working with a constant sense of anxiety because you can’t do your job properly.
Skill mix diluted
The skill mix of teams is also being diluted. When I joined a previous team we had a number of experienced AMHPs and senior nurses. It was great to have them to learn from. But as they left – some through retirement, some because they’d just had enough – they were replaced with staff who were on lower pay grades in order to save money. Those staff were still very skilled but our overall level of experience in the team was reduced and the new staff, many who had been transferred from wards, understandably needed support to adjust to community work as it’s a different ball game.
I see a similar trend in community services. Those teams used to have the staff numbers to allow you to build relationships with people receiving support. Now they rely a lot on unqualified support workers to do the relationship part and nurses are almost reduced to being medication machines and little else. The support workers are great but they aren’t clinicians so they might not pick up on signs that someone is deteriorating and people don’t get the level of clinical input they used to. Teams also spend so much time doing paperwork. Ticking the boxes. People are being seen less. The monitoring of people that we should all be doing just isn’t happening as much.
No time for outreach
Community teams on my patch, like plenty others, have absorbed assertive outreach functions too. The idea of assertive outreach was to work with people who are difficult to engage and are high risk of relapse. The point is they don’t want to see you. So, what has always been common practice, it’s good to build rapport with people outside of their home, maybe by going for a coffee or a meeting in another place. That’s less threatening than saying ‘I’m a mental health worker and I’m going to come to your home to ask you all sorts of questions that you don’t want to answer’. But now our services are told we’re not funded to take people out for those kind of things. It’s that kind of decision that makes me think – what the hell are we doing?
AMHP shifts
I still do AMHP shifts alongside my caseload. The lack of resources you’ve got to work with due to cuts by the trust and our local authority on the social care side is appalling. I was taught that it’s important for people (well, most of the time) to be near their families for their recovery. Yet if I assess someone as needing hospital admission, there’s hardly ever a local bed available. Instead we send them hundreds of miles away to private hospitals because they’re the only places with a free bed. What good is that?
Another assessment really sticks in my mind. I assessed a woman who had been held in a police cell after a crisis. I assessed her as needing hospital but there was no bed. I knew what I wanted for her. I knew what she needed. But I couldn’t get it for her. I had to leave this distressed, really mentally unwell woman in a police cell. And you go home and you know that. That’s the trouble. It’s not uncommon. You end up getting a sense of elation when you’re told ‘there is a bed’ because it’s so rare. That’s not right.
‘I left because it broke me’
I left one of my jobs because, if I’m honest, it broke me. As one of the few experienced staff members left I ended up getting allocated all of the most complex, difficult cases. I never got to balance that with people who were getting better. When we had more staff you had more time to see people who had gone through the process. That’s so important to give you perspective – to see people coming through the other end of crisis support – rather than only working at the acute end.
It’s only when you leave a situation like that, that you realise the pressure you were under. When you’re in it it’s the norm. You feel that you can’t stop, you don’t want to let anyone down – your colleagues and, most importantly, the people depending on you to help them.
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Welcome to the world of care providers, we get very little support when a system is in crisis. We have similar problems with DN’s discharge teams and some thankfully not all doctors surgeries
Living with risk is throughout the NHS.unfortunately those who can’t do so use up the resources that those that can treasure. This broke me in the end too. We need to support and educate each other but more than anything listen to those clinicians who are breaking.
Thank you. I read your article with sigh of grateful recognition. As a social worker/AMHP & practice teacher I’ve long said to my students that, to survive, they need to be able to tolerate high and enduring levels of anxiety. There’s a certain irony there which the psycho-analytically minded among us might like to explore… Everything you say echoes my experience. I did three assessments today as an OOHS worker, and th effect of cuts /austerity was apparent in each: a suicidal NHS employee who can no longer pay his mortgage despite working up to 96 hrs a week; a man who needs an habilitative/respite setting, not hospital; a woman whom I detained on s2 who ends up 50 miles & 3++ bus rides from home because there are no beds, and whose husband asked “[Town], I’ve never been there. Is it even in [our county] I gave him a 50 mile lift home and wondered how he will ever find the time and money to visit. That was my 14 hour shift. And in the meantime Adult social care calls were all backing up….dare I say that most services were better15 years ago?
My observation as a USER of social care and mental health services, is that both of these are professions which many people think are well-funded and that the pay they get reflects the high levels of skill they possess. Unfortunately, these people only become aware that their assumptions are completely incorrect, when they make use of these services. People in both of these, and other associated professions, are poorly paid in comparison to those with much less demanding jobs, and when they do get ‘burnt out’ the resources made available to them to recover from this, seem to be very basic and implemented in a haphazard and almost casual manner. People in all of these professions, are incredibly valuable individuals, putting up with situations and conditions that would not be allowed in any other form of employment.
I hope the person in this article manages to do something life affirming and leave Social Work – I used to work as a Social Worker in a CMHT and I hope I never have to return to the role of Social Worker. At least not until we stand together and make massive changes in this sick society of ours.
In my experience people move into these sorts of roles because they care and want to help. However how can we help anyone else by doing harm to ourselves? Constant stress and anxiety, a deluge of competing demands and a wage that does not in any way reflect the complexities of the job. Bedsides money cannot buy back the years taken off your life by engaging in such roles.
I also hope I never have to use such services because people can expect very little – how can Social Workers and others in the care sector expect to be able to help others when the structures in society are abusive? Governments are the problem not the solution and the bulletin for atomic scientists makes this clear by moving the clock to 3 minutes to midnight and highlighting how governments are failing in their duty on every level.
We need to engage in massive civil disobedience and make REAL change happen.
Sadly i have to agree with most of the comments posted. i am an amhp of 33yrs experience and i quit my job in 2014 because it was impossible to do my job. Like many social workers i was in an integrated health team..i found that i was being told to undertake health related work ..in order for them to realise their stats and targets .we served unfilled health posts..my social service managers abandoned me and colleagues to health..we protested only to have a response that we were to be performance managed. The local social service authority did not support me in my primary statutory role as an amhp. The cutbacks to beds,lack of police assistance, lack of ambulances etc meant that i could not admit extremely unwell people to hospital. When a bed was found it was often many miles away from family support….appalling.. i could not sleep at night after assessments that led to my having to section a person hundreds of miles from their family.