What happens in a Community Mental Health Team

What is a Community Mental Health Team (CMHT)?

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 (ASWs); 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 Psychiatrists, 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

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 Assessments (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 out 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 PBAs right until 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

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

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

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

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

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 PBAs 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 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.”