Wednesday, 17 August 2011

What Happens in a CMHT Mental Health Assessment?

When someone with a mental health problem goes to their GP, they are often apprehensive about what will happen next. Who will they be referred to in order to help them with their problems? Will they have to wait months, then see a psychiatrist in an office in a hospital many miles away? Or will they be asked to wait in a side room while the GP surreptitiously calls for men in white coats to drag them off in a strait jacket?

Let me reassure you: the last scenario is very unlikely to happen: for a start, psychiatrists and AMHP’s do not wear white coats. And I have never in the 30+ years I have been working with people with mental health problems seen a strait jacket in use in a psychiatric setting; I think nowadays they are only used by escapologists and stage illusionists!

Routes for referrals from GP’s to secondary mental health services for adults vary across the country, so it’s difficult to generalise. Many people will not even get as far as a Community Mental Health Team. Although approximately one in four people will experience some sort of mental health problem during the course of their lifetime, most commonly depression or anxiety disorders, most of those people will be treated solely by their GP.

In the last few years the focus of intervention for common mental health problems has been in Primary Care. The nationwide Improving Access to Psychological Therapies (IAPT) scheme has created teams of practitioners whose remit is to accept referrals from GP’s, or even directly from members of the public, for assessment and treatment for mild to moderate depression and other common mental health problems. They will then provide fairly short term treatment via talking therapies such as Cognitive Behavioural Therapy.

Many Mental Health Trusts also provide mental health link workers who work within GP practices and engage in brief assessment, treatment and sign-posting of patients referred to them directly by the GP.

Assuming that it is decided that a particular person’s problems are too complex or acute for intervention in Primary Care, they will, at least in the Charwood area, be referred for assessment by the Charwood Community Mental Health Team.

The Team will then arrange for an assessment appointment within two weeks of referral, or within 3 days if the GP considers it is urgent. Dire emergencies will go directly to the local Crisis Team for assessment the same day. The Charwood CMHT team consists of:
• a consultant psychiatrist
• a senior registrar, who is in the advanced stages of training
• a junior doctor, who may be a GP trainee or in the earlier stages of psychiatric training
• a clinical psychologist
• a cognitive behavioural therapist
• an occupational therapist
• several community mental health nurses
• several social workers, some of whom are also AMHP’s
• a couple of support workers

Any one of those may undertake the initial assessment. A person referred to a CMHT is unlikely to see a psychiatrist on the first occasion, unless the GP has specifically asked for a review of medication, or for confirmation of a formal diagnosis, or if the person has a complex presentation of a mixture of physical and mental health problems.

Millie – an example
Millie is 22 years old. She has presented to her GP in tears, saying she has been cutting herself because she feels so bad. She has felt like ending her life, but has made no actual plans. She has recently split up from her partner after he assaulted her. She is sleeping poorly, has lost weight, and is currently off sick from work. She had been on an antidepressant for about a year, and the GP had changed this about 3 months ago, as her mood had not improved.

Millie comes to the CMHT in some trepidation, not sure what to expect. In fact, the CMHT is one department in a modern, light and airy centre, which includes a GP surgery, a physiotherapy department, the community alcohol and drug service, a dentist, podiatry, and various outpatient departments. (However, you should have seen our old offices.)

The Masked AMHP greets Millie and invites her into a small but pleasant interview room. I begin by explaining to her what a CMHT is, and how any one member of the team may make an initial assessment, and that she is seeing me not because I am a social worker, but because I am a member of the multidisciplinary team.

There is a standard assessment process, as we have an electronic form that we have to fill in which covers a wide range of factors, including past and present risk behaviour, any forensic history, the use of alcohol or non-prescribed drugs, etc. But I begin with some obligatory basic information giving and gathering: I explain our confidentiality procedures, and ask her about her next of kin, religion, employment status, ethnic origins, and make sure we have contact phone numbers for her. I then read her a prĂ©cis of the GP’s letter (leaving out statements like “I would be grateful if you could see this sorry young lass”).

I then ask her to tell me in her own words what problems she has that she would like help with. I feel it is always best to begin with open questions which allow the person to unfold and explain their problems in their own way. Sometimes people are very reticent about talking about their problems; at other times, it is difficult to shut them up or keep them on track.

Millie is neatly and appropriately dressed. She is wearing makeup. She looks underweight. She has poor eye contact. She looks down most of the time, wringing her hands unconsciously. She speaks quietly and haltingly. All these observations are relevant to the assessment, as they help to give an impression of the person’s mood, and what their level of personal care is.

Millie says that she has felt low “for most of my life”. I ask her to tell me more about her life, beginning from birth. Does she have siblings? Did her parents live together, or did they separate during her childhood? How would she describe her childhood? Did she ever experience any form of abuse as a child?

As she talks she reveals that, although she had supportive parents, she experienced years of bullying at secondary school. That was when she first began to cut herself. She was intelligent, and obtained 10 A-C grades at GCSE. She started doing A levels, but then became pregnant at 17 by her boyfriend at the time and decided to leave school and move in with him. However, she lost the baby at 5 months, and the relationship broke down. She took a serious overdose, and needed medical intervention, although there was no mental health follow up at the time.

Millie moved back in with her parents for a few months, and got a job doing office administration. She has been working in the same work setting for over 3 years She then moved in with another boyfriend, and they lived together for a year, but he began drinking heavily and 6 months ago he beat her up quite badly. She has lived alone since then. She is still waiting for the court hearing, but in the meantime he has been harassing her by phoning and texting her, often when drunk, sometimes pleading with her to take him back, and sometimes making threats.

Any person’s life story is important: it can reveal a lot about the origins of current mental health problems. Gradually, using a combination of open and closed questions, Millie reveals important factors which can help to identify exactly what her problems are and how best to manage them.

There is no evidence on assessment of any psychotic illness. However, she does have symptoms of clinical depression, including sleep disturbance, loss of appetite with accompanying weight loss, and some suicidal ideation.

Towards the end of the assessment, which takes about an hour, I ask her if there is anything else she would like to tell me, or if there is anything she would like to ask me. She tells me that misses her baby, and starts to cry. She says she wants to join him. We talk some more about this. I am particularly keen to understand what she means by “joining”. She says she has been considering taking another overdose, but feels she is too cowardly to try it again. I then conclude the assessment and I inform her that the assessment will be discussed in the multidisciplinary team and she will be informed within a week or so what the outcome of the assessment was.

Although I have been developing a formulation of her problems during the assessment, it is afterwards, when writing it up, that I draw all the factors together and come to a conclusion to present to the team meeting. What is important is not just to know what her mental health symptoms are, but what caused them in the first place.

The bullying at school was clearly a significant factor. Her unhappiness and sense of powerlessness led to her beginning to self harm as a soothing strategy to release these emotions. Although she stopped by the time she entered 6th form, she has now returned to this strategy as a means of coping with her current feelings.

The miscarriage was also a key life event, and it had become clear that she was still grieving the loss of this baby. This sense of loss may have been reawakened by the ending of the second major relationship in her life.

Additionally, she was experiencing some signs of post traumatic stress as a result of the assault by her boyfriend. He had attempted to strangle her, and at one point she had thought she was going to die. This can be a risk indicator for the development of a subsequent full blown post traumatic stress disorder, although a formal diagnosis would not normally be made until symptoms had been in existence for at least 6 months. It was probably too early to decide this, especially as the trauma was being kept alive by having to wait for a court hearing for his assault, and her apprehension at having to give evidence. She was, however, receiving input from Victim Support. They were also helping her to deal with the ongoing issues of harassment.

All these factors had led to Millie experiencing chronic low level depression, which had now become worse due to the combination of adverse life events.

The final part of my assessment is to devise a draft plan for intervention. There are clear risk issues to consider: Millie has taken an overdose in the past, and is thinking of doing this again. She consequently needs ongoing involvement with the CMHT, with work to reduce risk. She also needs help to identify other ways of dealing with negative emotion other than self harming. The immediate plan would therefore involve the allocation of a care coordinator, as well as arranging for a medical review by one of the team psychiatrists, as Millie does not seem to be responding very well to her current medication. In the longer term, she may benefit from cognitive behavioural therapy, especially if her symptoms of post traumatic stress become chronic. This can also help her to change the thinking patterns which have led to chronic and recurrent depressive feelings. She may also need help relating to the loss of her unborn baby. There may be external services available for her to be referred to as part of her treatment.

I hope this example shows the thinking and reasoning that goes into a mental health assessment. It is vital to get the overall picture, and not just focus on identifying behaviours or signs that might indicate the existence the symptoms of a specific mental disorder. Labelling is not the most important thing.

I’m afraid that I can only describe my own experiences of assessment. I would like to think that every Mental Health Trust has thorough, consistent and comprehensive assessment processes, designed to meet the needs of people with mental health problems. All I can really say is this is what you should expect.

Tuesday, 9 August 2011

Does Mental Illness Preclude a Career in the Caring Professions?

A history of mental illness can certainly impact on people’s future life and work prospects, even if a person makes a full recovery. One consequence of a history of mental illness can be to affect your ability to live and work in certain foreign countries. I have often heard it said that if you have ever been detained under the Mental Health Act, then the USA will not allow you a visa. This is, however, not strictly speaking the case. The regulations actually state only that someone is not eligible to travel under the ESTA visa waiver arrangements if:

“(b) you currently have a physical or mental disorder and a history of behavior associated with the disorder that may pose or has posed a threat to your property, safety or welfare or that of others; or
(c) You had a physical or mental disorder and a history of behavior associated with the disorder that has posed a threat to your property, safety or welfare or that of others and the behavior is likely to recur or lead to other harmful behavior.”

There appears to be no impediment for someone with a history of mental illness who is in remission or controlled by medication, and the restrictions only apply where there has been, or is likely to be a recurrence of risky or dangerous behaviour.

In the UK, there is a raft of legislation that is designed to explicitly protect people from the effects of discrimination. In addition to the Human Rights Act 1998, Article 14 of which prohibits discrimination on grounds including disability, there are also the Disability Discrimination Acts of 1995 and 2005, and most recently the Equality Act 2010. The effect of this legislation is to protect people from discrimination for a wide variety of reasons. These include discrimination on grounds of age, religion, sex, race, sexual orientation, and disability.

The Equality Act 2010 makes it unlawful for an employer “to discriminate against or harass a disabled person.” An employer is also required to make reasonable adjustments to accommodate disabled people within the workplace. Interestingly, there is also protection for people “who are associated with a disabled person or who are wrongly perceived as disabled.”

A person with a disability is defined under the Equality Act as having “a physical or mental impairment”. That impairment must have “a substantial and long-term adverse effect on their ability to perform normal day-to-day activities”. Guidance to the Act suggests a wide range of mental health conditions and mental illnesses would be covered by this legislation, including: “depression, schizophrenia, eating disorders, bipolar affective disorders, obsessive compulsive disorders, as well as personality disorders and some self-harming behaviour”.

There is also an interesting list of conditions which would not be considered to qualify as a disability. These include: “fear of significant heights, underestimating the risk associated with dangerous hobbies, such as mountain climbing, or a person consciously taking a higher than normal risk on their own initiative, such as persistently crossing a road when the signals are adverse, or driving fast on highways for own pleasure.” Which seems to exempt the presenters of Top Gear from protection under this legislation.

It has happily been my experience that Public Sector employers in particular take their responsibilities in relation to people with disabilities seriously. I have encountered a number of people with a range of mental health problems who have successfully trained for and obtained jobs in social work or allied professions. There follow a few brief histories.

Joni was a woman in her 30’s whom I worked with intermittently over quite a few years. I first saw her when she was referred to the CMHT with a history of severe bulimic behaviour. Over a period of months, I helped her work through the issues from her past that had led her to have such problems with her self image. These included a father who was never able to give praise for achievements. On one occasion as a teenager she had obtained a distinction in a musical instrument examination with an overall score of 93%. Her father looked carefully at the certificate and then said: “If only you’d worked a little harder, you could have got 100%.”

Over time, she recovered and was discharged. Several years later, she was referred again. In the intervening time she had trained as a social worker and was actually in employment in an older people’s team in the same local authority that employed me. Then she had become pregnant, had gone on maternity leave, had her baby, returned to work – then the issues with self image and self esteem kicked in again. Her only way of managing this was to return to her bulimic behaviours, with the addition of liberal quantities of alcohol: “An open bottle is an empty bottle.”

This time, talking therapy did not work. She became more despairing and desperate, her drinking and binge eating became increasingly out of her control, and one afternoon, when I discovered her about to take all her medication, I arranged for her informal admission to Bluebell ward in Charwood Hospital.

Once she was there, she changed her mind about the admission. She was detained under Sec.5(2) and a request was made for her to be detained under Sec.2 MHA. Because of my close involvement in her treatment on a voluntary basis, as well as the fact that she was essentially a work colleague, I arranged for a social worker with no association with her to undertake the assessment, and she was detained under Sec.2.

She remained in hospital for several weeks. Her mood improved. She acknowledged that she had an alcohol problem. She agreed to take antabuse as a means of controlling her alcohol consumption. It was agreed to give her a trial dose. As a routine measure, she was breathalysed immediately before. She tested positive as over the limit. She was still drinking, even on the ward, even as she was about to start antabuse.
A specialist alcohol treatment centre was sourced, and she agreed to go there. This involved residential stays as well as outpatient appointments over many months. As the centre undertook complete care management, I did not see her again.

But a year or so later, I heard that she was working, as a social worker, for the neighbouring local authority.

Joan was 20 years old. She was two years through a course training to be an occupational therapist when she made a very serious attempt to kill herself. She had cut her wrists as well as mutilating her body with a knife, and nearly died before she was found by her flat mate. She spent a couple of months in hospital, which meant that she had missed too much of her final year to catch up.

I liaised with the college. She had been a good student, and they were keen for her to complete the course, providing her mental health was good enough. As her care coordinator, I worked with her through her recovery from depression. We also worked on the issues from her earlier life that had led to this extreme act. She responded well to treatment. By the end of the academic year I was able to reassure her tutor that Joan was well enough to be able to retake her final year. As this was in another part of the country, I did not have any further professional involvement with her, although I did hear that she had passed her course.

A couple of years later I happened to be visiting a psychiatric hospital in a neighbouring county, and was taken by a colleague to the staff canteen. Joan was there. She had a job as a psychiatric OT.

John was working as a qualified social worker in a voluntary agency working with young people leaving care when he had his first episode of bipolar affective disorder. I first met him while he was an inpatient. He had been on a short term contract, and it had ended. He was very despondent, because he believed that, with a diagnosis of bipolar affective disorder, he would never get another job as a social worker again.

I tried to reassure him. I talked to him about the legal requirement on prospective employers not to discriminate on the grounds of his mental illness. I gave him some case histories. I encouraged him to come clean on his applications about his medical history when the time came, but to point out that these experiences could enhance his practice as a social worker. The session appeared to go well, and he left in a more positive frame of mind.

So what was the outcome for John? Well, not all my stories have sad endings. John did get a job as a social worker in a local authority. And to the best of my knowledge, he is still in employment, despite, or possibly even because of, his bipolar affective disorder.