A GP might refer an out-patient but in-patients are generally allocated to a Community Mental Health Team (CMHT), prior to hospital discharge, which is normally made up of various multi-disciplinary professionals such as:
- Community Mental Health Nurses (CMHN) and unqualified support staff
- Social workers and Approved Social Workers (ASW’s) – Same as social workers, but (ASW’s) have undergone specific training in mental health law/ the Mental Health Act, which enables them to carry out Mental Health Act assessments with other professionals.
- Consultant Psychiatrist, Senior Registrar and/or SHO’s (Senior House Officers) who are Doctors undergoing their six months training in a particular area of medicine. In this case, Psychiatry.
- Possibly Occupational/Art/Dance/Music Therapists
The CMHT works with a person who may get help from one or two of these professionals or the whole team, depending on their needs.
As a Mental Health Nurse student, I was allocated to Alan, a CMHN who would be my supervisor for the duration of this placement. I was five minutes early, had a coffee and managed to introduce myself to a few of the team while waiting for Alan to arrive. It was eight fifty-five on a damp, miserable, Monday morning and this was not a happy bunch. Had they not been sitting behind the flexy plastic window, I might even have thought they were patients waiting to be told they’ll be held in hospital on Section 3 of the Mental Health Act 1983* (MHA) and have medication injected into their eyes.
I smiled as the front door opened and an older gentleman wearing a tatty tweed jacket, a moth-eaten jumper and a shirt that was so old, the collar was frayed. His well-creased trousers looked as though they’d had an argument with his ankles and his black plastic slip-ons squeaked as he walked. Still, his gappy-toothed smile was welcoming and as he stuck out his hand, introducing himself as Javid, he pushed open the inner door with his backside and I realised he was staff.
I explained who I was and Javid took me down to a dingy basement office, pointed to Alan’s desk and the one opposite that I could use and off he went. I went through my Practice Based Assessment (PBA’s), a list of evidence-based tasks to be carried out at each placement, to see which ones I might be able to meet sooner rather than later as I always liked to get a head start and not leave the PBA’s right til the end of placements. Thumbing through a patient file, gathering information, I could see a rickety old bike being chained to the railings and watched as the green wellies marched up the few steps to the front door then heard them thumping down towards the basement. The office door bashed open and there Alan stood. He pulled himself up to his full six foot plus, puffed out his chest and glared at me, demanding “What do you think you’re doing?” in a broad Scottish accent.
“Javid said I could look through……..”
“Is Javid your supervisor? No, he’s not. I am. Javid is and ASW and you. are. a. mental. health. student. Are you not?”
I almost stand to attention and shout “Yes. Sir!” Instead, I raised my eyebrows and stared him out for what seemed like an age. He turned on his heels saying “I’ll get myself a coffee and see you when I come back!”
This was the way Alan continued during the next few weeks, barking orders at me and ignoring any questions, feeding me snippets about his patients when he saw fit. He also told me he was married and had two children and that he was an ex-police officer, something I should have guessed. Either that or the Armed Forces. He was egoistical, belligerent and manipulative.
I was surprised one morning when Alan told me that I was to run his Depot Clinic, where patients come in bi-weekly/four-weekly to have their antipsychotic medication via injection. “You do know how give give injections, I presume?” he snapped”And don’t forget to check which side. I’ll countersign the medications charts when you’ve done.” I was so glad the first patient in told me to give the injection on the right buttock and as I went to sign the medication chart I spotted the small letter ‘L’ underneath the signature box, which I gathered meant that was the side the last injection was given. I would read at home later that the large muscles in the buttocks was the safest intramuscular site because it’s thick and located away from major nerves and blood vessels. You also gave injections on alternative sides to stop the build up of scar tissue on one side.
Sally, my first patient appeared sullen and I wasn’t sure I’d be able to engage her in idle chit chat before inserting the needle, something I hoped would help take the patient’s mind off the injection. However, she chatted amiably about me being a new student and asked whether I liked football. The needle was out and I let on that I was an Arsenal fan. “Blinding. Me too. I ain’t never been myself tho’, ave you?”
“Yes, I’m lucky. I’ve been to quite a few games.” I was scribbling my signature on her meds form when she turned her head to me and said “Come on, ‘urry up girl!”
“All done Sally.” Ha! I’d given my first real injection and she didn’t even notice. Her eyebrows shot up and I got a brief smile of approval as she buckled up her jeans. “You’re alright you are. She can come again Alan.” she gave me a knowing look and glared at him as she left the clinic. Not a word from him, just another of his withering looks as I passed him the meds form to countersign.
A month passed and Alan continued to arrive late. One morning, Javid asked if I’d like to go out and visit some of his patients with him and I jumped at the chance. We arrived at Anne’s house to see her in the front garden wearing a flimsy kaftan with bare feet twirling around on the grass, arms outstretched and head thrown back, singing.
Anne grinned when she saw Javid and waved him in with a dramatic curtsey telling us she was calling the children in for lunch. Four skinny under-twelves trooped into the living room, hungrily snatched up huge doorstep sandwiches and danced, skipped and jumped all over the two sofas as they munched while singing silly songs, clapping and dropping crumbs everywhere. It was like a scene from a West End Musical. They were clean, wearing all manner of clothing; some too big and some to small, all bare footed but they looked happy and were both well spoken and well mannered.
Anne’s had a diagnosis of bipolar disorder which used to be known as manic-depression, where a person has episodes of depression (feeling very low and lethargic) and mania (feeling very high and overactive). Unlike simple mood swings, each extreme episode of bipolar disorder can last for several weeks, or even longer, and some people may not experience a “normal” mood very often.
Javid allowed me to complete a mental health assessment, done by observation and direct questions, assessing things like mood, behaviour, appearance, thought form for speed and coherence, thought content for delusions, suicide, homicidal or violent thoughts, obsessions and perception, cognition for orientation to time, place and person, attention and concentration. Finally, we assessed insight, whether Anne knew her incessant chatter, thought disorder and behaviour wasn’t normal given the weather and both her and the children’s appearance. However, she didn’t believe she was currently unwell “This is nothing.” she chirped. “You’ve seen me worse Javid.”
Javid smiled, then stood and we bid our goodbyes, Anne and the children singing “Au revoir.” and waving. Sitting in his car, Javid talked me through the visit and agreed that yes, he had seen Anne worse but he would check the ward to see if there was a bed so that he could plan a voluntary admission during the next few days. He said that Anne would use all kinds of delaying tactics but would eventually agree to voluntary admission. She knows she has a chronic (long-term) diagnosis and is well known to services so she’s aware she would be admitted under Section 3 of the MHA 1983, where patients can undergo coercive interventions, such as enforced medication, seclusion and restraint.
After a few more home visits Javid and I returned to the CMHT around four fifteen, in time to complete our documentation, and to see Alan snap his briefcase shut, throw me a look of utter disdain and head for the door.
Alan’s lateness carried on, his behaviour remained erratic and his lack of interest or guidance was getting me down. There were days I was in tears despite the admin girls telling me to ignore him and making me laugh saying he just needs a good shag! So each day so I went out on visits with Javid or other staff who’d asked if I’d like to accompany them. I was gaining so much experience as the team were supportive and fed back to me my strengths and small areas that I could build on. Many said that I was really intuitive, had excellent communication skills, and had been proactive in achieving the high standards I’d set myself and overall they were impressed. I’d completed all my PBA’s and was pleased with the evidence I had attached, having made sure there were no names or numbers that could identify individual patients. All I needed now was for Alan to sign them off as having been completed.
The arrogant shit refused! He hadn’t seen me complete any of the tasks listed on my PBA’s so he would not sign them! He couldn’t possibly! Long story short, had to involve his superior who agreed that other senior staff I’d worked with could sign them off for me! I only got a huge 94%.
Note to self: I might have lost a battle but I certainly won the war.
* A depot injection is a slow-release, slow-acting form of medication. It isn’t a different drug – it’s the same medication as the antipsychotic taken in tablet or liquid form. But it’s administered by injection, and it is given in a carrier liquid that releases it slowly so it lasts a lot longer.