Thursday, 29 December 2011

In Praise of Psychiatric Services? (2)

Dr Rant
I’ve just tried to change my password to ‘Community Mental Health Team’ but Facebook said: contains too many useless characters.  (Facebook 16/12/11)

Sorry Community Mental Health Teams  (CMHTs) – I find this to be true – well certainly in my neck of the woods.   God help the unfortunate soul who experiences an exacerbation of mental health ‘ishoos’ while residing in social care for they are truly lost!

I have written about this before and unfortunately nothing has changed.  The CMHT completely ignore us (staff) in that they do not seek our input, our knowledge and our concerns.  Liaison – what’s that?  Do they consult the referring GP (?) – I tend to think not (and indeed sometimes know) as GPs are equally frustrated re the lack of communication and cooperation between ‘colleagues’ and that (wrong) decisions are made (by the CMHT) after a thirty minute interview with the poor resident in question.

Ted entered our home some five years ago – he does not have any problems related to memory but that of depression and apathy which has dogged him since a traumatic incident in early adulthood.   He is isolated due to social anxiety which increases his depression and feelings of hopelessness and low self-worth. 

This has been his life for nigh on thirty years and increasing apathy, hopelessness led to Ted being at high risk of self-neglect and increasingly vulnerable to those in society who ‘befriend’ him and rob him of his benefits and thus him becoming a welcome resident of our home.  Our home is now his home  (It is Ted's home - I/we have the privilege of working there!)

For some time Ted has become reflective re his personal situation and this in itself has led to a deeper depression (‘I am worthless’) and as he is comfortable in his home he is also able to express anger (‘I am useless!’) both verbally and physically (as in punching inanimate objects and destroying his own personal effects).

Ted has – for the first time – begun to self-harm.   He also exhibits behaviours that some might construe as sexual in nature – but to me (and I have discussed this with him) are an expression of his need to be loved and reverting to babyhood and the intervention required is to him, proof of caring.

Ted’s GP referred him to psychiatric services requesting the input of a psychiatrist.  In turn, said psychiatrist did not see Ted rather placing Ted’s future in the hands of the CMHT.   What is the purpose of the CMHT?   A CMHT meets the needs of people with mental health problems who don’t need a psychiatrist.

So it needs to be asked:  Does this little collusion of anonymity (psychiatrist and CMHT) have an agenda?    Why is the GP referral of secondary importance to that of the CMHT – who make their decisions based on a thirty minute interview without liaising with other interested professionals who know Ted?

The CMHT in their wisdom decided that Ted did not need to see a psychiatrist.  This decision – to Ted – was further evidence of his unimportance (‘Why is no-one interested in me?’).

Ted’s continued and deepening depression began to compromise his physical health in that he ceased to eat and had poor fluid intake causing an electrolyte imbalance which led to problems and the need for medication to counteract this.

Ted’s GP, who had long realised that Ted’s needs were beyond his expertise again contacted psychiatric services, pressing for the input of a psychiatrist and again this led to a swoop by the CMHT, who again decided that Ted did not need to be seen by a psychiatrist?

Six months ago, near death (malnutrition and dehydration), Ted was hospitalised.  He was at this time (finally) seen by a psychiatrist and when strong enough was transferred to a psychiatric hospital to treat his depression!

The psychiatrist contacted the home for a history of Ted and requested our thoughts – something the CMHT (and indeed the psychiatrist prior to this) did not!

It appears to me that the little collusion of anonymity ensured Ted paid a high cost both physically and mentally by denying him access to a psychiatrist – but that is what collusion of anonymity is all about – bouncing patients back and forth from one specialist/discipline to another with nobody taking responsibility for the patient as a person.

Ted is a person.

Before I close I would like to assure those who exist in CMHTs that this is a specific post to experiences in my neck of the woods and is not a gross generalisation of all.  I am sure that team members offer a vital hand to those in the community who do not need to see a psychiatrist.

Why do psychiatrists not take heed of GPs here?  Why in these instances are decisions left to CMHTs as to whether a patient requires the input of a psychiatrist – why does the psychiatrist not see the patient and make the decision him or herself?   Just wondering, that’s all…

What say you?

Anna :o]


Dr No said...

Anna - Dr No sees this as in large part a direct consequence of 'New Ways of Skiving' - the RCPsych's blue-print to allow psychiatrists to sit in their offices diddling paperclips while the CMHT troops do the real work. Only they don't, because as Ted's case shows only clearly, all too often the CMHT hasn't got a clue what it is up to.

Balint's collusion of anonymity normally refers to a local group of doctors/heathcare workers bouncing a patient from pillar to post. The RCPsych's 'New Ways of Skiving' takes that collusion and performs it on a collegiate pan-professional scale:

"In essence, NWW [New Ways of Working] is about using the skills, knowledge and experience of consultant psychiatrists to best effect by concentrating on service users with the most complex needs, acting as a consultant to multidisciplinary teams, promoting distributed responsibility and leadership across teams to achieve a cultural shift in services. It encompasses a willingness to embrace change and to work flexibly with all stakeholders to achieve a motivated workforce offering a high­ quality service [emphasis added]."

It may sound wonderful, but in practice it has been used disgracefully, as a licence to skive.

Frances Garrood said...

All that time wasted, and all that suffering for poor Ted.... How very very frustrating for you all! My sympathies, Anna.

NorthernTeacher said...

The well known phrase "hitting your head against a brick wall" springs to mind, Anna.

Dr No's para beginning "In essence" must be something that has been passed around various public sector whatevers before. If "consultant psychiatrists" is replaced by 'teachers', it could well have gone around my staffroom when I worked for a certain government quango teaching centre. Plus ca change...

Dr No said...

Northern Teacher - apologies - I didn't make it obvious - it is a quote from 'New Ways of Working' (itself linked to earlier on in the comment) and yes I am sure you are right that is is pandemic thinking in public services - medicine, teaching, and of course the police (CSOs...): all part of dumbing down, all part of why pay for highly trained arrogant opinionated Smart Alecs when a significantly cheaper assistant can do the job just as well?

That is not to say there is not a role for assistants/support officers: of course there is. The problems start when any role starts acting up above its station, and in so doing displaces the proper people who should be doing that job.

Lolamouse said...

This sounds so frustrating! I don't know how mental health services work (or don't)around where you are, but the issues sound similar to those around here. Unfortunately, it often takes a real crisis to get the services a patient truly requires, and then it's often too late.

Mama Zen said...

Ridiculous. Absolutely ridiculous.

Friko said...

I don't know Anna, I have no answer other than the pious wish that this might be an isolated case. I am sure it's not.

Happy New Year, nevertheless; may it be kind to you and all the Teds of this world.

Anonymous said...

"the RCPsych's blue-print to allow psychiatrists to sit in their offices diddling paperclips while the CMHT troops do the real work."

Hah, hardly Dr No! The handful of psychiatrists left spend their time fire-fighting, they'd love the chance to be assessing new referrals. But why would the PCTs pay for expensive psychiatrists when CPNs can do it for less while the medics get responsibility for any 'risk'?

We'll see whether the GP commissioners opt for an expensive consultant lead service with inpatient beds available when needed or follow the current trend of demedicalising mental health (just look at addictions, nary a medic to be found) with cheaper nurses and 'mental health practitioners'. I think I know where my money would be.

HyperCRYPTICal said...

Thank you for your welcome comments folks.

Dr No ~ Thank you for the link. The summary makes interesting reading and I too focussed on: “In essence, NWW is about using the skills, knowledge and experience of consultant psychiatrists to best effect by concentrating on service users with the most complex needs, acting as a consultant to multidisciplinary teams, promoting distributed responsibility and leadership across teams to achieve a cultural shift in services. It encompasses a willingness to embrace change and to work flexibly with all stakeholders to achieve a motivated workforce offering a high quality service.” (Unless a motivated workforce offers a high quality service - it is a meaningless little gem).

The Ten Essential Shared Capabilities make interesting reading too – I wonder if anyone follows their direction? (I am thinking especially of ‘Working in Partnership’ as this is glaringly lacking in my (geographical) area.)

As said the CMHT do not (ever) seek our input and after a CMHT swoop we hear no more from these fine folk (as it appears we as carer and often guardian of the resident do not count in the grand scheme of things) - unless we contact them – no copy GP letter – which after all is good practice . More importantly neither does the patient/resident – so much for working in partnership then.

(I lie – on one occasion it was decided that a resident did need further input from other ‘concerned’ professionals and was told that this and that would be implemented. Said resident is still waiting – five months on…)

Reading further, I can appreciate that psychiatrists indeed do have to concentrate on those with complex needs – but if it is left to the CMHT to decide who has complex needs… well there is the rub.

Frances ~ frustrating indeed!

Northern Teacher ~ I think Dr No’s follow-up comment answers this. The public sector is rife in dumbing down and dilution of services – and it is all probably/certainly down to cost.

Lolamouse ~ sad to hear the situation is similar on your side of the pond.

Mama Zen ~ it is indeed!

Friko ~ sadly it is not an isolated case.

Anonymous ~ reading would confirm that there is a serious ‘shortage’ of psychiatrists to fill consultant posts and yet there is a willing amount of locums to fill this gap – so in effect PCTs are paying for expensive psychiatrists. What can be done about this – I don’t know).

Reading (again) would suggest that psychiatrists were ‘for’ the creation of the NWW – were they or does the fancy literature presume they were?

NWW: 4. New and changing context: drivers for change. 4.7 There is a strategic move towards developing a competence based rather than a professionally based workforce.

This worries me greatly as it is obvious (if only my locale alone) CMHTs are not competent. CPNs may indeed be cheaper – but a CMHT does not consist of CPNs alone.
Is the medic who carries the risk of responsibility and accountability aware of the incompetence of the team that operates under ‘his’ direction? Probably not – and that is more worrying.

I tend to agree with your last paragraph and if indeed mental health is being demedicalised – I presume this only applies to the adult population for indeed the opposite appears to apply to that of children – where childhood is being medicalised left, right and centre?

Anna :o]

Promising Poets Parking Lot said...


Happy Happy New Year.

Appreciated your support of 2011,

Best Wishes for the year of 2012…

Your contribution is always welcome!

Lots of blessings and cheers sending your way.

See you soon.


Dave King said...

The perfect password - and they reject it! That's life!
A great New Year to you and yours.

Cockroach Catcher said...

Good post Anna. There are some clever people out there and unfortunately they are not on the patients' side.


A team absolve members from guilt psychologically,as used by many dictatorial regimes.

The psychiatrist then distance himself from the team's decision and BINGO, money saved!

Mental Illness (not Health) uses up money and there is no easy way out!!!

HyperCRYPTICal said...

Thank you for your comments Dave and CC.

CC ~ unfortunately the link doesn't work - please reprovide.

Teams surely do absolve guilt - bit like a firing squad really - no one knows who has the live bullet - and it would appear in CMHT - no one has it.

Poor patients - not fair at all.

Anna :o]

Cockroach Catcher said...

Or Copy
& paste

Am Ang

HyperCRYPTICal said...

Am Ang

Such is political correctness and its effort not to offend and offending many. The article itself is very amusing, and perfectly illustrates the idiocy of those who would alter our language to appease who knows who in this brave new world where everyone is nice.

When a student nurse, inpatients were ‘clients’ then and no better care was afforded them as a result of their new title – I have a post in draft written some time ago of these days – I may publish it one day.

Erm, did cut and paste upon your first comment and as said the ‘link’ didn’t work and still doesn’t.

Anna :o]

marit said...

This offered a lot of interesting insights for someone who does not work in this field. Although I don't know enough about this kind of thing to offer an opinion, I do agree with your emphasis that Ted is a person, and should be treated like one.

HyperCRYPTICal said...

Thanks for your kind comment marit.

The Teds of the world should always be regarded as a person - one day perhaps...

Anna :o]

christopher said...

There is a basic split between the use of power and money to service and to profit. The tendency is for profit to win when there is a conflict because the profiteers are actually more intimately involved with money and thus will struggle longer and harder in general. This happened in the US pretty much when Reagan as Governor spearheaded the movement in California. Costs of mental health were rising. Someone figured out a way to write the change so that it sounded good and also allowed the money to stop flowing to mental health efforts.

The US never recovered. There are now many people among the homeless in many cities including mine who were once the kind in institutions and safe. The kind of experience I had in 1967, a four month stay in a small hospital in the foothills above the San Francisco Bay area of California, is no longer available to anyone.

I came here through Magpie Tales

HyperCRYPTICal said...

This sounds pretty familiar Christopher as ‘Care in the Community’ was evolving during my time as a student nurse and indeed the hospital I trained in closed some five years later.

Although there were many flaws in the area of mental health then, despite this, hospitals provided a safe – if not perfect, probably far from it – environment. Those long stay patients were turfed out into the community in the name of enlightened progress and regrettably many were not able to function there and added to homelessness.

Mental health – probably the world over – has long been a Cinderella service and there is no doubt in my mind that Care in the Community was down to cost efficiency and not caring at all.

Greg Elias said...

All that time wasted, and all that suffering for poor Ted.... How very very frustrating for you all! My sympathies, Anna.