Thursday, 31 March 2011

In Praise of Psychiatric Services?

What does a Community Mental Health Team (CMHT) actually do?  Of course I do know what the remit of their existence is:  Meeting the needs of people with mental health problems who don't need a psychiatrist.

But what if your GP decides you do need the input of a psychiatrist, why isn't her/his decision acknowledged, respected and action taken, rather than the CMHT swoop down on you instead?

We have a sixty year old resident ('Winnie') with complex mental health problems including ongoing addiction.  You might think we are being remiss in not addressing her addiction but our hands are tied by Safeguarding Vulnerable Adults (SVA) and Deprivation Of Liberty Safeguards (DOLS) legislation, and of course, importantly, whether this legislation exists or not, Winnie has the right to choose her own path in life.

Winnie presents as quite a strong character with a seemingly happy disposition, but there are strong suggestions (of late) that all is not well.  I love my job and see my main purpose as that of promoting well-being and being 'there' for the residents.  I have regular daily chats with many residents and these chats, quite rightly represent the bulk of my work.

Winnie is one of these residents.  We chat about everything past, present and future.  As said, of late, there are obvious signs that all is not well and our chats have taken on a deeper nature.  She talks of a deep depression that she hides under her happy veneer and indeed, my last post is based loosely on that she has disclosed - the real Winnie.

Her depressions is something that she has coped with for the majority of her adult life.  She receives antidepressant medication and it has been enough - along with her own self-medication of alcohol - to control her symptoms until a recent event led to feelings of helplessness and hopelessness that dogged her in her early twenties.

We contacted her GP who is a good GP who visited Winnie in the home and spent time with her, listened to her, increased and augmented her antidepressants and referred her to psychiatric services.

Psychiatric services initiated a CMHT visit, although which professionals were represented in this team we do not know as we were not privy to this information.  Why might this be - perhaps the bad reputation of care homes and the assumption we would not be interested?  If this is the case - it is bad practice.

The team spent half an hour with Winnie and left - no staff being approached to give input into Winnie's situation.  A few days later, my manager was contacted by a psychologist (who had not been part of the team) to advise that the home was to be reported re SVA and DOLS issues in relation to Winnie.  Flabbergasted my manager asked why and the reason given was incredible.  He asked why he had not been contacted previously as to enable the team to be aware of the true facts and was met with an embarrassed silence.  We were not reported, nor did we receive a cc of the letter to the GP which is good practice and good manners as we are very much involved in Winnie's care.

Winnie continued to deteriorate both mentally and physically and my manager contacted the CMHT again requesting further input, only to be told that their work was done.

What is their purpose?

The good GP is bringing together a CMHT of her own making and being a good GP visits Winnie weekly as she shares our concerns.  In the meantime Winnie continues to suffer.  Hopefully, somewhere in the near future, Winnie will receive the input of a good psychiatrist, emphasis on good as we have four psychiatrists who serve the residents in our home.

One is a good psychiatrist - the old school variety of 'doctor knows best' who listens to and understands the real needs of his patients and follows up their care regularly.  His patients have the best outcomes.

The remainder are of the newer breed who offer choice-ism.  "Which tablets do you want to take?" and/or "I hear you attempted to strangle X - can we discuss this?" (if "No" to the latter it is not addressed!) and is all well and good until  you display florid psychosis and/or come very near to actually strangling X and are sectioned.  What kind of care is this?

You are never offered the choice of mental ill-health - but hey, even if you lack insight you can choose your medication based on the knowledge you acquired while being a medical student!  You were not a medical student?  You don't have a degree in psychiatry?   Never mind, your mental health issues may not be addressed - but hey, you do have choice!

You may think from the above that I believe those with mental health problems have no rights at all - but this is not the case as I am very BIG on the rights of residents, as is my home.  I believe they have a right to the best of treatment and not the superficial fluff of caring they receive now, although as said, even receiving superficial fluff takes an awful lot of time to get to as there is an awful lot of hoops to jump through first.  And you continue to deteriorate.

What say you?

Anna :o]


Frances Garrood said...

A thoughtful post. What particularly struck me was how right you are about what you called "choicism". I feel that while this is supposed to enable the patient/client, in fact it disables them. To be ofered a choice, when you are at a low ebb and haven't the backgound knowledge or experience to make it properly, merely causes bewilderment and reduces trust in the medical practitioner. Of course people should be able to discuss their treatment, and sometimes make choices, too, but it can be a bit like taking your car to be serviced, and then being asked whether or not you think the big end needs changing. You (probably) simply don't know. You want to be guided by an expert. That, after all, is why you're seeing them in the first place!

Dr No said...

Anna - an excellent post that describes how modern 'psychiatry' (doesn't) work.

This CMHT guff came about for a number of reasons. First and foremost the GMC applied 'equality' to medical teams, and pronounced that the first duty of a doctor was to be a team player. This then played perfectly into the hands of the psychiatrists, who had been exploring new ways to bunk off, only to make it sound better when they published it, they called it New Ways of Working. The key change was that instead of being referred to, and so under the care of, a psychiatrist, patients were referred to 'the team', and managed by, 'the team'. This freed up the psychiatrists to remain in their offices playing with their iPhones, while the patients got seen and managed by a quacktitioner...

...and occasionally, very occasionally, it works well, because the quacktitioners aren't quacktitioners, they are very experienced capable CPNs. But most of the time it is a ragamuffin bunch of over-inflated risk averse tick-box ticking protocol pushing lip smacking quacktitioners - and the patients get a very raw deal - just as your Winnie did.

cb said...

Not all CMHTs work this way. OK, I work in one and I can feel the rage rising amid those who post and comment here. I absolutely work my hardest to promote and provide good care to all those I come into contact with. As I work in specialist team for over 65s, I can't imagine going into a care home and not consulting extensively with staff but I'm not going to become an apologist for people who clearly believe we are 'quacktitioners' or 'overinflated risk averse tick-box ticking protocol pushing lip smacking types' :)
Not all teams operate in the same way, if that is any reassurance.
Just as in care homes where the quality varies massively, so is the case with CMHTs, and GPs and all services.

It shouldn't work that way of course.
Make complaints.

Hold my hand: a social worker's blog said...

This is a very interesting post. I feel for Winnie, and I am glad you are an advocate for these patients/residents.

Thanks for stopping by my blog, and commenting on my story. That case particularly generated a debate in terms of loyalty and ethics. Some people asked, why doesn't he divorce her then? Because of the finances? Other people were just glad that she had those two caring people in her life, at that stage of her life.


Dr No said...

cb - Dr No does have a rather trenchant style, and sometimes that is useful to get people to sit up (and yes Dr No agrees sometimes it can be off-putting too).

You don't need to be an apologist - from your comment it appears that you belong to that group of non-quacktitioners Dr No identified (and sang the praises of). The real point is that too many CMHTs do have too many [enter your own term for quacktitioners here], and that situation is made worse by New Ways of Bunking Off. The picture of the consultant in his or her office playing with an iPhone will be all too familiar to far too many people - and as a Dr, Dr No would say these doctors are just as much the villains, if not more so, than the 'ragamuffin bunch of over-inflated risk averse tick-box ticking protocol pushing lip smacking quacktitioners'.

Dr No hopes that when he is 65 and needs a CMHT visit, he will find himself in your patch.

HyperCRYPTICal said...

Cheers for your comments folks.

Francis: A perfect analogy! It is right and proper that patients should be able to discuss their treatment and make choices - but these must be informed choices and not a case of a psychiatrist abdicating his responsibilities which often seems to be the case. There is one particular psychiatrist... I wont say much more other than his patients are often left in a state of crisis...

Dr No: Psychiatric services in the district I work in are abysmal. If you enter our home as a resident with a psychiatrist 'attached'- well you are lucky even if your psychiatrist is a joke!

If you move from another district then you have to be reassigned another psychiatrist. This may take months even if you are in crisis. If a care manager is not in place - you cannot see a psychiatrist however dire your need. GPs do what they can - but to no avail as they cannot fight the system which is unbendable.

If sometime after admittance - which may be years - and you need to see a psychiatrist then the above (post) happens. It is not right!

cb: Please be assured that the post was not an attack on CMHTs but on psychiatric services (in my patch) in general.

GPs report to us that this problem is ongoing and despite complaints, it continues. When CMHTs deem that X does not require any imput, despite requests from homes and GPs - it is a kick in the teeth for all involved, in particular the resident/patient who is hung out to dry.

With regard to individual GPs, SWs, CPNs, nurses, psychiatrists et al - with most we enjoy exceptional relationships that benefit the residents. With some - definitely not as their inflated ego's cause much antagonism - to the detriment of the residents.

Of course, as you rightly say, there is good and bad in every profession and indeed, some care homes are hell holes!

I will write to you cb as I am unsure as to whether I have clarified that the post was not an attack on all social workers and especially those in CMHTs.

Doris: I especially enjoy your blog as you are care home based and I am interested in your stories which always are kind and thought provoking.

Anna :o]

Cockroach Catcher said...

Excellent Post; chronic conditions cost money, so they made money selling the asylums/mental hospitals then they stop calling you patients so that you do not need a doctor and now soon the Health Secretary will not be responsible to your health. The next group of patients will be the over-weight ones.

Manzanita said...

My daughter who lives in another state, has suffered with mental problems her whole life. Lately the psychiatric people have been calling me and asking me to sit in on conference calls. I did just that on 2 calls this week. My daughter seems to feel confident with me there. For many years, I couldn't get any information about her but it seems to be slightly changing, in her case.
Interesting and timely post.

Kit Courteney said...

Excellent post, Anna.

My partner is a CPN and works within an Early Intervention Team. From what I can tell, he is seen as a GOOD one! He loves his job but does find it very frustrating at times.

In theory, the whole system SHOULD work very well. We've moved on from the Dark Ages - Mental Health issues are more 'out there' now, surely...

The reality is that some services are barely working let alone improving the lives for those 'service users' (ugh!) who bloody need them!

HyperCRYPTICal said...

Thanks for your comments folks!

CC: It's all pretty grim, isnt it? The changes began while I was doing my training - patients became clients, hospitals closed and the 'clients' were thrown out into the community, a few name changes later they became 'service users' and now they find it very difficult to gain access to the services they need to use!

Manzanita: It is heartening that changes appear to be occuring with regards to your invitations to become active and informed in your daughters care. Hope it continues.

Kit: I can imagine that your partner finds his work frustrating at times and I am sure he is an excellent CPN. Your last sentence perfectly describes the problems encountered by 'service users' (ugh too!) in the city in which I work.

Anna :o]

Friko said...

A grim picture indeed.
What use is choice when you don't have the mental or physical equipment to deal with it.
But then, choice comes with being a customer rather than a patient.

30 yrs or more I had some psychiatric treatment and when the psychiatric nurse finally washed her hands of me she left me with this parting shot: "you are as sane as you'll ever be, there's no point carrying on."

HyperCRYPTICal said...

Hi Friko

I can well believe the parting shot.

When I was a student nurse the majority of qualified staff were very nice people, that said the majority of them were in the wrong job!

The patients were treated like criminals - as if their crime was mental ill-health. Empathy, compassion didn't enter into their care.

I could not understand why patients were treated badly at a time they needed help most. I didn't want to become part of it and vowed, that once qualified, I would never work on a ward again - and I haven't. Always in a community setting of some kind, for the last fifteen years - care homes.

I would like to think that all this has changed, but reading mental health blogs, patients often report their increased despair when hospitalised.
Hopefully, they are a minority.

Anna :o]

Friko said...

thank you Anna.
I am glad to say that, although still suffering from bouts of mild depression, I no longer need (fingers crossed) serious help except for session with my NHS counsellor. She is a competent and caring person, well able to deal with someone who is "only as sane as she'll ever be".