Kay Bennett is an Approved Mental Health Professional and social worker in a Community Mental Health Team based in the South East. She works within secondary mental health services, supporting people longer term who are referred from a GP, and makes decisions about whether individuals meet the criteria for admission to hospital under the Mental Health Act, something she tries to avoid if at all possible. She has kindly shared with us an insight into her working life and the challenges her clients face day to day, to be published over our next two blogs.

Warning: This blog contains sensitive depictions of mental illness, depression and suicide that some readers may find distressing.

Kay BennetWhat I do

As a social worker, I work on long term cases under a framework for mental health called the Care Framework Approach (CPA). My caseload is currently with adults 18+ who experience severe and enduring mental health problems. I can work with my clients for variable amounts of time, from six months to four years or more, and it is important that I get to know them well.

My clients experience symptoms of serious mental illness. Often this means a primary diagnosis of psychotic illness such as schizophrenia or mood disorders such as bi-polar affective disorder, personality disorder, obsessive compulsive disorder or severe anxiety and depression. Many also have complex social circumstances.

My role is part of a multidisciplinary approach that integrates health and social care; as a social worker within the CMHT my client’s needs are met under one service. This is not always the case within mental health services, with some areas splitting services for mental health and social care between local trusts and the local authority, between community nurses and social worker’s respectively.
My team and I assess our clients under the Care Act against specific eligibility criteria to determine how best to meet social care needs, such as via a package of care for example. We champion their care needs within the health service, so the service user receives support from professionals with both medical and social care training.

I fulfil my Approved Mental Health Professional (AMHP) duties on a duty roster, taking it in turns to be on call on the frontline for my region. This means being the first port of call for individuals requiring assessment under the Mental Health Act. These individuals may have been found on a bridge in a suicidal state, could be unwell at home or in police custody for example. We assess and try to encourage them to engage with least restrictive options for care i.e. additional support from the crisis team, but if this is declined or not appropriate we can also consider admitting them to hospital either voluntary or under section for assessment and treatment.

I apply a biopsychosocial model, a care approach founded on the interconnection between biology, psychology, and socio-environmental factors in mental ill-health. My team’s multidisciplinary approach consists of doctors, nurses, psychologists and support workers, and we bring different strengths to the table. We have a person-centred approach to care, working with hospitals to facilitate the safe discharge of individuals back into the community under a care plan.

The stigma of mental illness

I am pleased it has become commonplace to talk about mental health but in my work, I know only too well that while the phrase “mental health” has now gone mainstream, “mental illness” is still a stigma. It is well understood that we all have variable mental health, but we do not all suffer from mental illness. Diagnoses such as schizophrenia and personality disorders are still stigmatised and conjure up images of dangerousness.

Recovery goals

My aim is to help people live a stable and happy life. One of my regular tasks is to identify a client’s recovery goals which is included in their care plan and refer them to appropriate services and pathways for care and support. The definition of recovery varies from person to person. A person with chronic mental health problems might never ‘recover’ in a standard sense, similar to some physical health issues, but we can maximise quality of life and ability to manage symptoms successfully. We might work with people who are repeatedly in and out of hospital who benefit from additional support to manage fluctuating symptoms, management of risk to self and possibly others, and reviews of medication to help find the best combination which works for them. It is sometimes necessary to explore supported housing options to help maximise independence in the community.

The recovery goals I set with my clients could include connecting people who have lost any semblance of a social network or finding healthier networks for anyone surrounded by people who are a negative influence. Some of my clients will have dual diagnoses such as mental ill health and substance misuse. They may be exploited by people who are invested in maintaining their alcohol or drug dependency. Colleagues and I are sometimes required to safeguard people at risk of or experiencing abuse. I may also be required to support people to manage their mental health whilst they choose to maintain a lifestyle involving substances. The link between mental illness, complex social circumstances and substance misuse can be difficult to break.

We might try several ways to bring more purpose to a client’s life, such as workshops, crafts, activities or sport to get them out and about, provided we can persuade them to engage with these activities. We have local services we can refer clients to for support, such as recovery colleges, psychological and educational courses, or craft courses. It may be singing groups, voluntary work or helping people to get back into work.

We have a service that supports people get back into employment, connecting them with local employers and providing support with CVs. The government is trying to increase employment opportunities for those who experience mental health problems. The employment is often part time to begin with, to slowly increase confidence and skills and to prevent scenarios whereby clients lose their entitlement to benefits too soon which can cause hardship should a deterioration in mental health or difficulties within the role occur. Employment can reduce loneliness, provide a sense of purpose and improve self esteem. Managed carefully, this can be a virtuous cycle.

The limits of medication

Some of the long-term symptoms and side effects of medication for serious mental illness can further impact mental health by causing shakes, nausea, constipation, and other side effects that can limit people’s movements and ability to go outside and socialise. Positive symptoms of serious mental ill health can include delusions and hallucinations, whereas negative symptoms include withdrawing, not wanting to leave the house, a lack of get up and go; these are especially symptomatic of schizophrenic-type illnesses.

Medication may treat positive symptoms and manage voices, but there’s limitations on the efficacy of medication for negative symptoms, therefore we also focus on social and psychological support to help manage symptoms. Some clients also experience emotional dysregulation, may struggle to manage dysfunctional relationships and a history of trauma and abuse where medication alone cannot treat these issues.

Trying to break the cycle

Most of my clients are trying to break the negative cycle experienced with symptoms of mental illness and complex social circumstances towards gaining greater stability.

One example may be younger people who might have transitioned from children’s services with a history of being in foster care. They may keep returning to a parent because they want answers about their past, but this may trigger overdoses, suicide attempts or self-harm due to feelings of abandonment or rejection for example. They want to feel loved but do not have the skills or emotional development to sustain healthy relationships, so may spend time in A&E receiving treatment for wounds, turning to substances or going in and out of hospital. My team support people who seriously self harm, some of whom live alone or in supported accommodation to build a therapeutic relationship, increase confidence and activities to reduce episodes of crisis.

Feeling powerless

In my work I have encountered some distressing cases where individuals have experienced horrendous abuse or trauma at the hands of others. My client’s difficulties may be a result of this trauma and survivors of abuse may be further let down by delays in the legal and courts system, impairing their ability to seek justice, receive therapy and move on. One service user who experienced a serious sexual assault has needed to wait approximately three years for their case to get to court. Reliving this trauma is difficult and daunting, particularly when memory may have become impaired, alongside managing symptoms of low mood, anxiety and suicidal thoughts. At the same time this could be their only hope of moving on.

Some clients who experience chronic suicidal thoughts and feelings may frequently self-harm i.e. overdose. They may not truly intend to end their lives although sadly there have been occasions when this has occurred by accident. Managing risk of suicide is part of the job and we do so on the understanding that these behaviours can often help people to cope and manage distress. We work together to try and keep clients safe and manage their risks whilst acknowledging we may not be able to remove these entirely.

Colleagues and I also experience working with individuals, albeit very occasionally, who sadly end their lives for various reasons. This is particularly difficult to manage, both personally and professionally, particularly within what is often perceived as a blame culture within services.

Sometimes we feel powerless to help change how someone may be feeling, at least immediately, or manage a lack of resources within the system hindering access to support. Social workers are often trained to support people to problem solve, but I have learned that sometimes we need to sit with someone in their despair, listen and validate their anger and sadness. This can also be considered therapeutic and helpful to an individual.

Case Study: Positive Risk-Taking

One of my clients was a married woman in her 40s with children, who had a successful career, and had repressed a history of horrific trauma and abuse in her childhood at the hands of a family member. She experienced many flashbacks a day, both inside and in public, where she dissociated entirely, “leaving the room” and physically shaking. She was very high-risk to self and had compartmentalised her life to lock her abuse away.

She had a past eating disorder which returned, and she restricted food to the point where she collapsed in our appointment. It soon emerged that her husband may have also physically assaulted her although this could not be proven and despite trauma, was insisting on maintaining sexual relations within the marriage. She feared her children would be taken away from her following the involvement of children’s services.

I helped her to recognise that if she did not eat, she might collapse in front of her kids which places their welfare at risk. We worked closely with a private psychologist, the GP and the police were also involved but she did not wish to pursue any charges. It was clear to the psychologist and I that she would not survive a court case due to difficulty managing symptoms of trauma and a lack of support around her to pursue a conviction. I did not disclose information to the police without her consent to maintain our therapeutic relationship.

Her condition worsened and on one occasion she called me from the top of a carpark in a suicidal state. I drove to her and persuaded her to get into my car, also persuading the police (who I was duty-bound to involve) to give her plenty of space and attend in unmarked police vehicles: if she saw them, she may have jumped for fear of being detained.

She was under a great deal of stress and struggling with symptoms of trauma. The GP wished to admit to hospital under the Mental Health Act which holds significant weight. I did my best to encourage colleagues to support me to positive risk take in this case. I feared that if we acted on anxiety and immediately admitted to hospital when she had already lost so much, there was high risk she would take her own life as soon as she was discharged from hospital. This presented a dilemma as both options presented risks and the stakes were high.

A person-centred decision to drive her back to the community mental health team building allowed her time to process emotions, to speak to the doctor and engage with some additional support as part of a plan to return home. I informed her that I trusted her to choose to keep fighting and challenged thoughts that her children would be better off without her.

At other times, a positive risk-taking approach is not possible or appropriate. There was a second occasion, prior to a weekend, when she was at very high risk of suicide. The crisis team and I persuaded her to go into hospital voluntarily. She was in hospital for a couple of weeks but crucially, she felt that she was in control of her own situation and her treatment and care was achieved using least restrictive options.

This client was discharged from care a couple of years later. She received therapy, returned to work and joined a music group. She felt the service made a real difference to her, especially through the relationships and rapport built with the service. For me this was a case of balancing risk and duty of care with the need to give choice and control to the individual. One of the most important things we do is to promote a person’s rights and achieve a balance between keeping people safe whilst exercising autonomy as far as possible. By doing so, we have kept many people alive.

Read Part 2 of this blog


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