What happens in a Community Mental Health Team?

What is a Community Mental Health Team (CMHT)?

Community Mental Health Teams are multi-disciplinary
Community Mental Health Teams are made up of multi-disciplinary professionals

Have you ever wondered what happens in a Community Mental Health Team (CMHT)? Let’s take a look.

They were developed in the UK to deliver Care in the Community in the late 1980s. This was a British policy of deinstitutionalisation; treating and caring for physically and mentally disabled people in their homes rather than in institutions. 

A GP might refer an out-patient, but in-patients are generally allocated to a CMHT prior to hospital discharge. These CMHTs are made up of various multi-disciplinary professionals such as:

  • Community Psychiatric Nurses (CPNs) and unqualified support staff
  • Social workers and Approved Social Workers (ASW’s); social workers who’ve undergone specific training in mental health law; the Mental Health Act 1983. This then enables them to carry out Mental Health Act assessments with other professionals.
  • Consultant Psychiatrist, Senior Registrar and/or Senior House Officers (SHOs) who are Doctors undergoing their six months training in a particular area of medicine. In this case, Psychiatry.

Once referred to the CMHT, an assessment would be completed to build up an accurate picture of a person’s needs. The patient might get help from either one or two of the above professionals, depending on their needs.

My first placement at a Community Mental Health Team

How a basement CMHT might look
How a basement CMHT might look — Image by Washingtonpost.com

As a Mental Health Nurse student, I was allocated to Alan, a CPN who would be my supervisor during this placement. I arrived early so I had a coffee and introduced myself to a few of the team while waiting for Alan.

It was eight fifty-five and the team’s overall mood matched the weather that stormy Monday morning. Had they not been sitting at desks, behind the flexy-plastic window, I might have thought they were patients with depression — just staring blankly into oblivion.

I smiled as the front door opened and an older gentleman walked in. He was wearing a tatty tweed jacket, a moth-eaten jumper and a shirt so old, the collar was frayed. His creased trousers looked as though they’d had an argument with his ankles and his black plastic slip-on shoes squeaked as he walked.

Still, his gappy-toothed smile was welcoming. He stuck out his hand, pushed open the inner door with his backside and introduced himself as Javid, a Social Worker.

I explained who I was and he took me down to what looked like a fusty old storeroom. He pointed out his desk, Alan’s desk and the one opposite that I could use, and off he went.

Student nurse Practice Based Assessments

I went through my Practice Based Assessment (PBAs) to see which ones I might be able to meet — sooner rather than later. Students have a list of evidence-based tasks, to be carried during placements, which are assessed for competency by their supervisor. This was a lengthy process so I always liked to get a head start and not leave the PBA’s right ’til the end of placements.

While idly thumbing through a patient file, I happened to look up and saw a rickety old bike being chained to the railings outside. I watched from the basement window as a pair of green wellies marched up to the front door. The wellies stomped about a bit before thundering down towards the basement.

The office door crashed open and there stood Alan! He pulled himself up to his full six-foot-plus, puffed out his chest and glared at me. “What on earth do you think you’re doing?” a broad Glaswegian accent rasped. Think Billy Connolly!

“Javid said I could look through……..”

“Is Javid your supervisor? No, he’s not. I am. Javid is an ASW and you. are. a. mental. health. student. Are you not?” He turned on his heels saying “I’ll get a coffee and see you when I come back!”

And this was how Alan continued over the next few weeks; barking orders at me and ignoring any questions, or feeding me wee snippets about his patients.

Depot injections by Community Mental Health Team

Intramuscular depot injection administered by Community Mental Health Team
Intramuscular depot injection administered by Community Mental Health Team

I was surprised one morning when Alan told me I was to run the weekly Depot Clinic under his supervision. This is where patients come every 1-4 weeks to have antipsychotic medication via intramuscular injection.

Some patients prefer this as they tend to forget or refuse to take their daily tablets. Other patients must have medication by injection under a Section of the Mental Health Act 1983. If a patient is known to be non-compliant with medication, Depot injections are often recommended during Multi-disciplinary team (MDT) meetings.

“You know how to administer injections, I presume?” snapped Alan. And without waiting for an answer, “don’t forget to check which side they had their last injection. I’ll countersign the medication charts when you’ve done.” I’d observed several injections during my in-patient placement but I’d never actually administered one. I told Alan and all he did was nod; indicating me to just get on with it.

My first patient was due in soon so I checked her medication chart and spotted the small letter ‘L’ underneath the signature box. I gathered this meant that their last injection was on the left buttock so this time it would be on the right. Injections sites were alternated to stop the buildup of scar tissue on one side.

Administering my first depot injection

Preparing depot injection
Preparing depot injection — image by Pixabay

Sally, a 36-year-old female, appeared sullen and I wasn’t sure I’d be able to engage her in idle chit chat before stabbing her with the needle.

However, she chatted amiably about me being a new student and asked whether I liked football. The needle was out — and I told her I was an Arsenal fan. “Blinding. Me too. But I ain’t never been to a game.”

I did take her along to a match some years later, but that’s another tale. Anyway, there I was, scribbling my signature on her medication chart when she turned her head to me and chirped “Come on, ‘urry up mate!”

“All done Sally.” Ha! I’d given my first real injection and she didn’t even notice. Her eyebrows shot up then I got a wink and a smile of approval as she buckled up her jeans.

“You’re alright you are. She can come ‘ere again Alan.” She gave me a knowing look and glared at him as she left the clinic. Not a word from him, just another of his withering looks as I passed him the chart to countersign.

My first Community Mental Health home visit

Community Mental Health Teams work with patients in their own homes
Community Mental Health Teams work with patients in their own homes — Image by Pexels

A month passed and Alan continued to arrive late every day. One morning, Javid asked if I’d like to go out and visit some of his patients with him, and I jumped at the chance.

We arrived at Anne’s house to see her in the front garden barefoot and wearing a flimsy but colourful kaftan. She twirled around on the grass, head back and arms outstretched as she sang. Julie Andrews popped into my head and I fondly remember Anne whenever I hear “The sound of music”.

Anne grinned when she saw Javid and waved him in with a dramatic curtsey, then called the children in for lunch. Four skinny under-twelves trooped into the living room and hungrily snatched up huge doorstep sandwiches.

The kids danced, skipped and jumped all over the two mismatched sofas as they munched. They sang silly songs and clapped loudly, dropping crumbs everywhere. Their likeness to the much loved Von Trapp family didn’t go unnoticed.

They were clean, wearing all manner of clothing; some too big and some too small, all barefoot, but they looked happy and were both well-spoken and well mannered.

Bipolar disorder

Bipolar disorder and mood swings
Bipolar disorder and mood swings — Image by Crazyhead comics

Anne had a diagnosis of Bipolar disorder which used to be known as manic-depression. Someone with Bipolar has episodes of mania (feeling very high and overactive) and periods of depression (feeling very low and lethargic).

Unlike simple mood swings, each extreme episode (high or low) of bipolar disorder can last for several weeks, or even longer. Bipolar disorder is treated with mood stabilisers such as Lithium or Valproate, which were all originally made for treating epilepsy.

Community Mental Health Assessment

Javid asked Anne if it was okay for me to complete a mental health assessment, done by observation and direct questioning, assessing things like:

  • mood, behaviour and appearance
  • thought form for speed and coherence
  • thought content for delusions, suicide, homicidal or violent thoughts, obsessions and perception
  • cognition for orientation to time, place and person, attention and concentration

Finally, I assessed her insight to gauge whether Anne knew her incessant chatter, thought disorder and her behaviour wasn’t normal, given the weather and both her and the children’s appearance. However, she didn’t believe she was currently unwell “This is nothing.” she chirped. “You’ve seen me worse Javid.”

Javid smiled, then we stood to bid our goodbyes, and I couldn’t help but giggle when Anne and the children burst into song “So long, farewell, Auf Wiedersehen, adieu. Adieu, adieu. To you and you and you.”

Sitting in his car, Javid talked me through the visit and agreed that yes, he had seen Anne worse? “Really?” I asked. He nodded and chortled. However, he said he’d check to see if there was a bed so that he could plan a voluntary hospital admission over the next few days.

Javid said that Anne would use all kinds of delaying tactics but would eventually agree to voluntary admission. “She knows she has a chronic (long-term) diagnosis and she’s well known to services. She’s aware that if she doesn’t go voluntarily, she’d be admitted under Section 3 of the MHA 1983”. This means patients can undergo coercive interventions, such as enforced medication, seclusion and restraint.

Mental Health documentation to be completed

CPNs have to complete lots of documentation
CPNs have to complete lots of documentation — image from Pexels

After a few more less-exciting home visits Javid and I returned to the CMHT around four-fifteen, just in time to complete our documentation.

Alan threw me a look of utter disdain as he snapped his briefcase shut and headed for the door. Thank God for the weekend!

Alan’s lateness carried on, his behaviour remained erratic and his lack of interest or guidance was getting me down. There were days I was in tears, despite the admin girls telling me to ignore him, and making me laugh.

Every day Alan was late I went out on visits with Javid or other staff who’d asked if I’d like to accompany them. I was gaining so much experience as some staff were supportive and fed back to me my strengths and small areas that I could build on.

My Practice Based Assessment

Most of my PBA’s had been completed I and was pleased with the evidence I’d attached. I’d made sure there were no names or numbers that could identify individual patients.

The staff I’d worked with wrote on my PBA’s that I was really intuitive and empathic, that I had excellent communication skills, and had been proactive in achieving the high standards I’d set myself. Overall they said they were impressed. All I needed now was for Alan to sign them off as having been completed.

The arrogant shit refused! He hadn’t seen me complete any of the tasks listed on my PBA’s so he would not sign them! He couldn’t possibly! Aaarrgghh!

Over to you

But it got worse……….. I’ll do a short follow-up. But in the meantime, I’m happy to answer any questions and look forward to hearing what you think about care in the community. Does it work? Or even, just say “Hi.”

Should we report our Mental Health colleagues?

Would you put yourself in the firing line and report a colleague’s poor practice?

My last post “Poor standards discovered at mental health units” was instigated by The Guardian’s grim report in the Private Sector. I followed on by writing about a placement I’d had, only one two-week elective placement in Private Unit and it was just as grim. However, I had many other placements and also worked within the NHS and I’m afraid it was equally as bleak in some places.

I wrote of the nurse who came in laden with pillow, slippers and big blanket every night shift and once patients were in bed she made herself comfortable on the sofa where she slept ’til around six a.m. She wasn’t the only person who slept but the majority of staff woke after an hour or two and returned to duty.

I didn’t believe anyone should sleep whilst on duty on busy acute mental health wards but, as a student, was advised by colleagues not to rock the boat when I mentioned it. There would normally be two qualified nurses and one nursing assistant on duty during the night shift, on a twenty-bedded (plus) ward and if someone was sleeping that only left two staff to deal with any admissions or any emergency that might occur.

I was no spring chicken. I’d returned to studying at the grand old age of thirty-six and was classed as an adult learner. An adult who knew what was right and wrong – so I couldn’t sit by and ignore ‘sleepers’ as it made the shift unsafe for both patients and the non-sleeping staff. The NMC Code of Conduct 2015 states ‘ work with colleagues to preserve the safety of those receiving care.’ and I would quote this to the nurse in charge and would many times hear ‘Look it’s just what we do.’ or ‘Everyone does it.’ and ‘We all take two hour breaks here and if you want to sleep, it’s okay.’

I stood my ground and told senior staff that if this continued I’d have no option but to report it. Subsequently I noticed there were no ‘sleepers’ when I was on duty but I’d later heard that I was a ‘splitter’, someone who ‘split the team’ by complaining about poor practice.

I completed a placement in the community and I hated it. I had to work with miserable burnt out nurses, those who’d left the hustle and bustle of the acute wards for quieter and easier nine-to-five jobs in the community. As I’ve previously mentioned, my Supervisor was regularly thirty to forty minutes late so I latched onto other senior nurses, asking if I could do anything to help or could I accompany them on patient visits.

I was often met with belligerence and tutting and found many of them had huge chips on their shoulder. ‘They should have got promotion.’ ‘They didn’t win any awards.’ ‘They shouldn’t have to be walking the streets at their age.’ ‘They’re fed up with students.’ Blah blah, flippin’ blah.

Their own bad moods and failures often impacted on relationships with patients as they clicked their teeth, tutted and whinged as they assessed patients in their own homes. “Tsk, George why is this flat a mess? If you can’t look after yourself you go in (to hospital).” They’d do a quick ‘how are you?, are you sleeping well? are you eating well? and are you taking your medication?’ then they’d leave.

There was never with any kind of encouragement, always with a negative or condescending comment. Oh my word, give it up. Leave the job. Change career. Retire! Ffs!

Quite often, on my days off, I would spot community staff in Tesco around three or four p.m. doing a large shop then sitting down for coffee and cakes when they should have been at someone’s home. That’s when you see in patient’s notes “Knocked two or three times and patient not in.” and you can see the same comment documented for weeks at a time!

I mentioned this during a ward round, when the Psychiatrist was discussing a patient who’d been recently admitted and looked like a homeless person; with matted dreadlocks and long, dirty nails. He was one of the patient’s who’s notes read ‘Patient not at home.’ for 6 consecutive months so he’d clearly not been seen in the community.

Later, when the visiting (Community Psychiatric Nurse) CPN had returned to her office she’d told her colleagues and boss what I’d said. I got a short, sharp, round-robin email telling me to speak with the community team manager before gossiping. Oh how I smiled as I saw that the Psychiatrist had responded before I could, stating that I had done the right thing and leave it at that.

Did they think I liked having to complain? Still, as a student learning how to become a good mental health nurse, I complained, time and time again and each time, I hated it.

Some time later and having worked on my first acute mental health ward for about six months, I was awarded the Trust’s ‘Most excellent Newcomer of the Year‘ which came with a nice cheque (donated by a local company), flowers and a lovely piece of inscribed crystal that now sits proudly in a dusty cardboard box somewhere. As I walked through my colleagues to the lecturn to receive my award I heard the whispers behind covered mouths ‘Tsk. That’s her. That’s the splitter!”