My first placement with a CMHT
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 1983, 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.
The CMHT works with a person who may get help from one or two of the above professionals, 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 so I had a coffee and introduced myself to a few of the team while waiting for Alan. It was eight fifty-five and their overall mood matched the weather on that stormy Monday morning. Had they not been sitting at desks, behind the flexy plastic window, I might have thought they were patients waiting to be told they’re being placed on Section 3 of the Mental Health Act 1983 (1) and are due to have medication — injected into their eyes.
I smiled as the front door opened and an older gentleman walked in. He was wearing a tatty tweed jacket, a moth-eaten jumper and a shirt 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, he pushed open the inner door with his backside and he introduced himself as Javid, a Social Worker.
I explained who I was and Javid took me down to what looked and felt like a fusty old storeroom. He pointed out his desk, 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. I always liked to get a head start and not leave the PBA’s right til the end of placements.
While thumbing through a patient file, gathering information for one of my PBA’s, I happened to look up saw a rickety old bike being chained to the railings. I watched as a pair of 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. Think Billy Connolly!
“Javid said I could look through……..”
“Is Javid your supervisor? No, he’s not. I am. Javid is an ASW and you. are. a. mental health student. Are you not?”
I almost stood to attention. Instead, I raised my eyebrows and stared back at him 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 over the next few weeks, barking orders at me and ignoring any questions, feeding me snippets about his patients – when he saw fit.
He 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 not a nice man. Rather, he was an egoistical, belligerent and manipulative git.
I was surprised one morning when Alan told me I was to run his Depot Clinic (2) under his supervision. Patients come to the clinic bi-weekly or four-weekly to have their antipsychotic medication via intramuscular injection. “You do know how give give injections, I presume?” he snapped “And don’t forget to check which side. I’ll countersign the medication charts when you’ve done.” I had observed several injections during my in-patient placement but I’d never actually administered one.
My first patient was due in soon so I checked her medication chart and spotted the small letter ‘L’ underneath the signature box, which I gathered meant that was the side the last injection was given. Injections sites were alternated to stop the buildup 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 told her 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 then I got a wink and a brief smile of approval as she buckled up her jeans. “You’re alright you are. She can come ‘ere 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 chart to countersign.
A month passed and Alan continued to arrive late every day. 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 and barefoot. She twirled around on the grass, arms outstretched and head thrown back as she sang – Julie Andrews popped into my head. In fact, as I sit here typing, the classic film, The sound of music, has just started on t.v. and every time I see it, I remember Anne.
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 and hungrily snatched up huge doorstep sandwiches. They danced, skipped and jumped all over the two mismatched sofas as they munched. They sang silly songs and clapped loudly, dropping crumbs everywhere. Their likeness to the much loved Von Trapp family didn’t go unnoticed.
They were clean, wearing all manner of clothing; some too big and some to small, all bare foot, but they looked happy and were both well spoken and well mannered.
Anne 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 (high or low) of bipolar disorder can last for several weeks, or even longer, and some people might not experience a normal mood very often. Bipolar disorder is treated with mood stabilisers such as Lithium or Valproate, which is actually an anticonvulsant medication (also known as antiepileptic medication), which were all originally made for treating epilepsy. Epilepsy is a neurological disorder that can cause seizures.
Once we were on our own, Javid asked Anne if it was okay for me to complete a mental health assessment, done by observation and direct questions, assessing things like:
- mood, behaviour and 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, I assessed her insight to gauge whether Anne knew her incessant chatter, thought disorder and her 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 to bid our goodbyes and I couldn’t help but giggle when Anne and the children burst into song “So long, farewell, Auf Wiedersehen, adieu. Adieu, adieu. To you and you and you.”
Sitting in his car, Javid talked me through the visit and agreed that yes, he had seen Anne worse? “Really?” I asked. He nodded and chortled. However, he said he would check to see if there was a bed so that he could plan a voluntary admission over 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 she’s well known to services. She’s aware that if she doesn’t go voluntarily, she would be admitted under Section 3 of the MHA 1983. This means patients can undergo coercive interventions, such as enforced medication, seclusion and restraint.
After a few more less-exciting home visits Javid and I returned to the CMHT, around four fifteen. We were just 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. Thank God for the weekend.
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!
Every day Alan was late 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.
Most of my PBA’s had been completed I and was pleased with the necessary evidence I had attached, having made sure there were no names or numbers that could identify individual patients. The staff I’d worked with wrote on my PBA’s that I was really intuitive and empathic, that I had excellent communication skills, and had been proactive in achieving the high standards I’d set myself. Over all they said they were impressed. 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, I had to involve his superior who agreed that other senior staff I’d worked with could sign them off for me!
The admin girls mychieviously phoned me to ask about my results and I boasted – I only got a huge 94% for these PBA’s. Guess who they couldn’t wait to tell!
Note to self: I might have lost a battle but I certainly won the war.
(1) Section 3 allows for a person to be admitted to hospital for treatment if their mental disorder is of a nature and/or degree that requires treatment in hospital. In addition, it must be necessary for their health, their safety or for the protection of other people that they receive treatment in hospital. Section 3 is used where the person is already well known to psychiatric services or following an initial assessment under Section 2.
Under a Section 3 you can be detained for up to six months in the first instance. This could be renewed for a further six months and then for periods of one year at a time. Section 3 can only be renewed following an assessment by the doctor responsible for your care (Responsible Clinician or RC). Each time the Section 3 is renewed, a review of your current care and treatment is carried out by the Mental Health Act Managers.
(2) 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.