This article really resonated for me because I have
worked in both the youth and adult Forensic Psychiatric systems in B.C. This
area of social work practice is very invisible and not well understood at all.
It is highly specialized and to me, infinitely interesting.
Clients in the Forensic system are amongst the most stigmatized, marginalized and vulnerable people I've ever worked with. I consider myself to have been very fortunate to have worked with the clients I had in these systems. I learned a lot working with folks in Forensics, as well as their family members and other professionals.
Learning people's stories, often related to a lack of care in the civil mental health system, leading them to become more and more ill and later, committing crimes while mentally decompensated, inspired me to speak out publically, in the media, to advocate for improved mental health access and systems. Nobody in B.C. is really doing much in the way of systemic, or other advocacy, on the issues of mental health. The system continues to be eroded with no end in sight and no accountability on the part of the Health Authorities, or the B.C. government. This means that preventable tragedies will continue.
Andy McNicoll hears from social workers
tasked with supporting people who have committed serious offences while
mentally unwell, alongside managing any risk to the public.
Community Care, August 14, 2013.
'Is anyone in the red zone’? The question is asked each and every day at Lambeth’s forensic
community mental health team’s staff meeting.
It refers to whether any of the team’s 154 forensic patients are
showing signs of posing a danger to themselves or the public.
These
are people whose enduring mental health
conditions have been linked to them committing offences of varying
severity in the past, who are now (where possible) supported in the
community.
“We have to make sure that the whole team is alert to the fact that
someone’s situation is worrying,” explains Eddie Wilde, who manages the
multidisciplinary team's social workers.
“There may be symptoms or behaviour that suggests someone may need to
be brought in quickly, such as someone expressing dangerous thoughts or
ideas that they want to harm somebody,” he adds.
Risk and recovery
This dilemma of trying to do everything possible to help people stay well in the community while staying alert to any risk to public safety is what these social workers, and their nursing colleagues, face every day in their roles as care coordinators.
It’s no easy feat. Social worker Lorraine Spence explains that these
care coordinators have seen “everything you could think of”, ranging
from compulsive shoplifters to people who have committed violent and
sexual offences.
“There are sex offenders, paedophiles, people that are deemed to have
untreatable psychopathic disorders. We have seen people that have
killed or committed violent offences, things like theft, armed robbery,”
says Spence.
'Forensics is a whole different side to mental health. Sometimes people
who come into it without experience can be shocked by what you read
about people from all sorts of backgrounds. Anybody can become unwell' Lorraine Spence, social worker
“Forensics is a whole different side to mental health. Sometimes
people who come into it without experience can be shocked by what you
read about people from all sorts of backgrounds. Anybody can become
unwell.”
The community team sits within the South London and Maudsley NHS
Foundation Trust (Slam). Most clients come to them after being
discharged from River House, a medium secure unit at Slam's Bethlem Royal Hospital. Some will previously have spent time
at Broadmoor high-security psychiatric hospital.
‘You don't know what someone has gone through'
The types of offences involved in some cases could see
people bluntly demonised as 'monsters' in the two-dimensional world of
the tabloid press, but social workers take a more holistic view.
Their job is to look at the person as a whole, not their offending or
illness in isolation, and, as one of the team tells me, cases involving
even the most serious offences are “rarely black and white”.
“The press doesn’t give people a balanced view. You don’t know what a
person has gone through. When I read some histories, you see what
someone’s parents did to them, what they were exposed to and it can be
horrendous,” says Spence.
When she started in forensic social work, Spence made a point of
meeting or contacting a client to get to know them a bit before reading
their full offending history.
“I used to work in probation and there was one incident where I had
to find accommodation for a serious paedophile and, to be honest, being a
mother I found it really difficult. So when I went into forensic social
work I decided I would take the person as I found them, meet them
first, and then read their full notes afterward,” she says.
Paul Mukasa has been a social worker on the team for a few months and
previously worked for five years at Broadmoor. He tells me it's easy
for people “to be influenced by what you read in the papers” and admits
his wife often asks him (“using language I don’t want to use here”, he
laughs) why he chooses to do this branch of social work.
“When you go into social work you want to try to help people. Some of
these guys come from very dysfunctional families, some of them are very
ill when they’ve committed an offence. That could happen to you or me,”
says Mukasa.
Being a care coordinator
So what does being a care coordinator in this team involve? Mukasa explains that a lot of the role is about
supporting people
to access and link into community resources - employment support
projects, community groups and the likes - alongside assessing various
risks such as the likelihood of someone relapsing, reoffending or taking
their own life.
There’s plenty of paperwork too, including Mental Health Tribunal reports,
Care Programme Approach documentation,
the HCR-20 forms that assess the risk of someone committing a violent
offence. The team also have to provide regular updates to the Ministry
of Justice on any clients who are on restricted discharge under Section
37/41 of the Mental Health Act.
Working with police and other agencies, including children’s social
services, is also key. For example, tricky cases where patients with a
violent or sexual offending history want to negotiate access to see
their young children often demand input from multiple agencies.
“We might make a judgement about a person’s risk but child protection
social workers might not always trust it or agree with it,” admits
Mukasa.
Another element of the team’s work is engaging with patients’
families, explains social worker Yuk-King Wong. She says that people
faced with the, often quite daunting, move from a medium secure hospital
back into the community are “going to need their support mechanisms”.
“That can be very difficult. Families or relatives have to go through
a process themselves if one of their relatives has done something that
is quite hard for them. It could be anger, it could be shame, it could
be guilt,” says Wong.
'Families or relatives have to go through a process themselves if one of
their relatives has done something that is quite hard for them. It
could be anger, it could be shame, it could be guilt' Social worker Yuk-King Wong on working with families
“And also, we have to go through a process with our clients to find
out where they’re at in terms of their rehabilitation. A lot of the
reasons people are in forensic mental health is because they have
committed crimes when they were unwell.”
“So when they have been stabilised in their mental health they have
to go through a process of realising and acknowledging that they have
done something quite horrible when they were unwell so that’s another
realisation for them to adjust to,“ she adds.
Rewards of the job
So what is the best part of being a forensic social worker?
For Aimee James, one of the team’s social workers, seeing people who
have spent large parts of their lives in psychiatric institutions be
supported back into life in the community is particularly rewarding.
“You’ve worked with someone's family, their carers, their support
workers and eventually you see them progress through the system and in a
couple of years they’ve got their own flat. I think that’s one of the
really positive things,” she says.
Wong says similar, and tells me that seeing one client who spent over
40 years in secure institutions “thrive” in the community has been a
high point.
Resource pressures
Inevitably, when discussion turns to the hardest parts of the role
the unrelenting squeeze on both NHS and local authority resources crops
up again and again.
The care coordinators’ caseloads are increasing as part of the
NHS-wide drive to close psychiatric beds and shift more care into the
community. At the same time the team’s capacity is falling. Spence's
social work post will not be replaced and, when I visit, a nursing
vacancy needs filled. Access to occupational therapist and psychologist
time is also patchy (the team used to have a part-time OT and full-time
psychologist).
Some team members are concerned that the pressures to free up beds –
an issue across England – is leading to some people being discharged too
quickly only to end up back in hospital weeks later. Others feel their
increasing caseloads have seen opportunities to do real community-based
social work with clients overtaken by the risk management side of the
job.
'No matter what struggles we have in this team outside or with
resources, no matter how busy we are, somebody will always lend a hand.
That’s one thing I really, really love' Lorraine Spence, social worker
Social work manager Wilde tells me that this is the “toughest time”
he's experienced in terms of the resources (or shortage of
them) available.
“The message from government about ‘doing more with less’ really has
hit home,” he says. “We’ve got to try and work out how we deal with
that. As part of a wider management team we’ve got to work out what we
prioritise. One thing that is really important is that we have the staff
to deal with the pressures.”
Wilde says that senior management at the mental health
trust “recognise we’re an important part of the service” and says
discussions are underway to try and resolve some of the issues the team
is facing.
Various “exciting projects” are also in the pipeline
such as a social-worker led initiative looking at placement options for
challenging patients and some promising work with charities and housing
associations, he adds.
“In many ways I feel inspired by the team and the way discussions are
going about what the NHS and local authority would like to do with it,”
says Wilde. “But everyone is waiting for changes to happen and not just
have all of these good ideas on a board. They want to know that the
cavalry is on its way.”
Andy McNicoll is Community Care’s community editor.
