Shadowing in a Community Mental Health Team

So this week I’ve been fortunate to have 3 days shadowing in a community mental health team – very different from anything that’s come before.

The first thing that I noticed and loved was the multi-disciplinary setting – we were sitting amongst occupational therapists, psychologists, nurses and social workers, which just feels like a really broad learning experience.

My first day involved going on two visits. I found the first one quite difficult – we were visiting someone with very developed dementia, and their child has given up their life to be a full time carer. This obviously happens a lot but I just felt so bad for them – they’re really cut off from the outside world, cannot engage with their parent at all, barely leave the house..and finally through creative use of their personal budget, have been able to get a laptop and hookup to Facebook – that’s the extent of contact. It upset me to think about – and I think one of the differences working with older people vs children is the ability to distance yourself. With YP – you can say, I didn’t have this childhood, poor them – with older people – it could be you, or your parents one day – and that’s quite a big thought to face each day.

The second visit was also an eye opener and comes back to the issue of taking things at face value, one I’ve discussed before. We met someone else with dementia who discussed her active daily life, amongst other things – and I went away feeling quite positive. It turns out that none of these elements are real. I guess they were a few decades ago, but not now…

It was really interesting to note little observations and checks the Social Worker does to monitor how the service user is doing – have they bought milk recently? Is it in date? They said they’re paying their bills – but can they show me they know where their bills are? Can we do a brief financial assessment – check how much they think their weekly food shop is for example; Check the carers logbook – have the carers been coming when they say they will etc.

I was fortunate to be shadowing a social worker with endless patience for my many questions. And with a huge variety of books for me to read – from psychiatric handbooks, to guidance on the mental health act and mental capacity act.
I learnt more about the differences between neurotic and psychotic conditions, about the MMSE – mini mental state examination - often done with people with dementia as a quick assessment.

On my second day I went to the multi-disciplinary meeting all morning, where each case is discussed. I really enjoyed this and thought it was so useful how each profession could chip in with advice about different cases. And for me, it was just interesting seeing different debates and protocols:

- one case was perceived to be a safeguarding issue, so a strategy meeting would be arranged asap, potentially involving the police
- in another instance it was unclear what more this team could do for the s/u so a case conference was going to be called involving everyone concerned with the s/u – family, people at the day centre they attend etc – and the s/u themselves would be invited
- they discussed the need for one s/u to go to residential care and how under s7 of the MHA, a patient can go into guardianship (with agreement of the closest relative, different to next of kin), the guardian may be a social services authority or any other person if the authority agrees to it. I have been reading about this further – the guardian must visit them at least every 3 months and the duration of guardianship is usually 6 months with the possibility of further renewals.
- The guardian can send someone to residential care, or make a decision on their care regime, without s/u’s consent – but cannot prescribe treatment to them. (A community treatment order is used to ensure a patient is taking treatment while still being in the community rather than needing to be detained in hospital.)
- The use of an IMCA (independent mental capacity advocate) – they’ll be involved where serious medical treatments are proposed and no one else can be consulted about the patient’s best interests or where there is a proposal for the patient to be accommodated in a care home or hospital – they will represent and support the individual, ascertain his/her wishes and consider courses of action.
and lots of small but to me interesting debates i.e:

- different children wanting their parent to live near them in a residential care home – who decides etc? Although comes down to capacity of individual themselves
- those who are diagnosed with dementia cannot attend just any residential home – they have to be dual registered to specifically work with those with dementia
- hard to engage with one s/u but they spend all their day in church – should SW-er visit them there? Or actually is it good they have their safe space uninvaded by social workers….if it’s easy to monitor their wellbeing by calling the church
- the importance of updating risk assessments and discussing doubling up on certain visits!


I also learnt more about setting up mental health assessments – to section someone. And read a best interests assessment form to assess whether the deprivation of liberty in a particular case was the best decision made in that instance – i.e was it done to prevent harm to the person themselves or to others, and proportionate to the risk posed. (I’m not explaining this well as its actually pretty detailed – see Stuart Sorensen’s blog for lots of detail about deprivation of liberty safeguards/DoLS)

I attended a training session about the importance of reducing prescriptions of anti psychotic medicine to those with dementia – it seems its often prescribed for behavioural elements such as irritability and insomnia, rather than psychotic elements – and there are many side effects that are not always considered in the detail they should be, such as strokes – this is a national target.

My final day I spent doing lots more reading. Particularly lots of reports for mental health act assessments, observations of what goes on in a mental health ward, and interviews with people after they had been sectioned – particularly interesting. I enjoyed reading the reflective reports (part of the AMHP portfolio) discussing whether the social worker felt that the assessment had been carried out in an anti-discriminatory way and the importance of trying to match gender and race where possible between service user and those carrying out the assessment.

Anyway I’ve waffled on a lot in this post about the detail. I’ve learnt lots in a few days and its particularly interesting given that first mutterings this week about my first placement suggest it may be in a voluntary mental health setting – but will know more soon.