This question popped up on social media the other week. Over all my time working in mental health I’ve often seen this debate going on, although it’s sometimes framed Generic Vs Specialist working.
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For those outside of the UK, or those who haven’t had the pleasure of working in mental health, it’s probably worth exploring what care care coordination is. So in the uk, people with more complex mental heath problems are seen within secondary care. This is likely to be a community mental health team. If you are among the most complex of the most complex you will get a care coordinator. The mental health charity Rethink say a care coordinator will:
Fully assess your needs:
Write a care plan which shows how your needs will be met
Regularly review your plan with you to check your progress
Your care coordinator should consider the following needs:
Your mental health needs
Medication and side effects
Employment, training or education
Personal circumstances including family and carers
Social needs
Physical health
Potential risk to yourself or others
Problems with drugs or alcohol
What you can probably add to the above list is going to safeguarding meetings, arranging reviews and professionals meetings, being the go to person when the person you work with is in crisis – which might involve getting extra services involved, arranging an admission or mental health act assessment or staying involved once someone is in hospital.
I spent a fair few years being a care-coordinator for people. Mostly in a CMHT, but also in Assertive Outreach and Early Intervention. What I learned over time was that care coordination is boring. Not all of it, the opportunity to build a relationship with someone over months or years was fantastic. The filling out of forms was not. The bureaucracy and associated paperwork is mind numbingly dull. In all my time doing these forms no one was particularly interested in the quality of them, merely that they had been done. And the pressure to fill them in was relentless. Not only was there the need to complete an assessment and risk assessment and crisis plan almost within an hour of meeting someone, but these had to be updated and signed by the client every time you did a review and every time there was an admission. Unmet Need forms needed to be completed and it seemed that for anything to happen, there was a form that had to be filled out. There were days that I filled in forms about people that I wasn’t seeing because I was filling in forms. It felt pointless, an exercise in box ticking and (to steal a phrase from my old lecturer “As if the performance management aspect of the primary task had become the primary task itself”.
In stark contrast to the organisational anxiety and zeal around the completion of forms was the total disinterest of those who were in the service looking for help. This isn’t to say that they weren’t very concerned about the quality of what they were receiving, just that the filling out of forms was something that got in the way of the work, rather than made it better. The only times care plans became important for those I worked with was when things had gone very badly wrong. Obviously some sort of system is required to identify problems and how they will be addressed, but for me the entire system seemed set up to demonstrate that ‘something was being done’ often at the expense of anything being done at all.
With the paperwork out of the way (it was never out of the way, it just went further away from the front of your mind for a bit) there came the real work of actually helping people. This could be disrupted quite quickly. A client in hospital appealing their detention? A 2000 word report is required. A phone call saying a relative is concerned? You’re going to need to follow that up.
All the above is what my nursing, social work colleagues and I did day in, day out. They would also do periods of ‘duty’ where they would man a phone in the office and be the first port of call for anyone phoning the office. My memory of the spectrum of calls involved everything from a man who wanted to die to a nun who was organising a coffee morning who wanted to know if one of our patients was allowed a cake. It was chaotic, but it was enjoyable and rewarding.
While I was working in the CMHT there was often a lot of pressure to work differently from the rest of the team. Despite the fact that many of those in the service had been there for years and had histories crammed full of neglect, abandonment and abuse – the OT department were keen for all the work to be done in 12 weeks. This could be anything – anxiety management, healthy eating, linking into voluntary work, supporting to return to education….all of these and more – as long as it could be done in 12 weeks. If part of the reason that you were in the CMHT was that you had difficulty trusting others and believed that life would always be a shit as it had been – then that was you shut out from the 12 weeks of gold. A ‘lack of motivation’ was something to be penalised for, rather than something to be curious about. It seemed like there was a desire to provide a primary care service within secondary care for the noble reason of….I don’t know. There seemed to be no sense to it at all.
So there’s a view that when things are at their best, the work within mental health is structured, consistent and predictable. OTs often want to work in this way as it’s often the time that you feel most confident in what you are offering and you see the most benefit to those you are working with. The problem is that pretty much everyone wants to work in this way. I’ve never seen a social worker turn cartwheels at the prospect of writing a mental health act report nor seen a delighted CPN cancelling a group because a patient hasn’t been seen for 3 days. Few people relish doing duty. But….somebody has to do these things. Some of the jobs in the CMHT are boring, soul destroying and take you away from what you’d rather do. The question I always consider is why these relatively less rewarding jobs should be the domain of ‘others’. I know a lot of OT’s who would say that arranging a mental health act assessment isn’t the role of an OT – and maybe it isn’t, but it isn’t the role of a nurse or social worker either.
I have 2 concerns:
Concern the first
If we are precious about the work that we do, if we see ourselves as massively different to the rest of the CMHT I worry that we argue ourselves into being less useful than the rest of the team. Teams will advertise for generic posts that are nurses or social workers while we exclude ourselves from opportunities to show our value. I was in a meeting once where an OT was complaining about psychiatrists wanting people to come to them rather than going to where the others were – “It’s as if their time is more valuable than hours”. I wanted to feed him his payslip. OTs bring a unique contribution to the MDT but it isn’t worth any more or less than our nursing and social work colleagues. Let’s be team players and get dirty with the rest of the gang.
Concern the second
I work with people who are often dangerous to themselves. At one point I think I did this quite badly but after years of duty, crisis management, supervision and time with Lived Experience Practitioners I’m now seen as someone to look to for advice and support when working with people who might die. I’m going to suggest that this is relatively rare for an OT and I really don’t think it should be. Not knowing who is going to come through the door is exciting. Talking through difficulties with those who are suicidal is rewarding. In the past my OT managers actively steered me away from doing duty and responding to whatever problem someone had at that time. They encouraged me not to work with people who were chaotic and they gave me the message that anyone living with high risk was the domain of some other discipline. Had I listened I could now be in a place where I worked in a CMHT with a sense that self harm, suicidality and acute mental health crisis is someone else’s job – which would be ridiculous as that seems to be the majority of the work of the CMHT. We do ourselves no favours at all when we refuse to develop skills in some of the most pressing problems of mental health.
In a perfect world the bureaucracy of care coordination would be minimised and we would all do the therapeutic work that we wanted. In an imperfect world we need to help out with the work that our colleagues resent just as much as we do. Don’t be an OT that doesn’t help the team. Don’t be an OT who disappears when things get tough. Consistency and reliability doesn’t always mean being in a room on time for people planning on how to hold things together. It might mean being round their house while their world falls apart.
Keir provides supervision, consultancy, training & therapy via beamconsultancy.co.uk
Many thanks to Hollie @hoppypelican, Leanne Algeo @luvlea85, Sophie and Amy Boot @amyelizaharriet for kindly looking over the drafts of this blog and giving some useful feedback. Any errors, typos and bizarre ideas are entirely mine. If anything is coherent or makes a modicum of sense that is purely down to them.
The Diagnosis of Exclusion 