Maria needs help. Remember that.
So after a few weeks of Crisis In The Community she turns up in the police cells after shouting and screaming in the street. Just boyfriend trouble but it spilled out and the neighbours got involved and there’s a touch of arson and a bit of self harm….anyway upshot is, she’s in the cells and then gets assessed and ends up voluntarily on the ward. Boyfriend wants nothing to do with her now. Its over, he’s had enough. Remember that.
Maria makes friends quite quickly on the ward. This makes staff suspicious. They report that she doesn’t need to be there. But she’s now homeless. She’s taking up a much needed bed. Gradually she has no input from staff and spends her days doing her own thing. Only sleeping in the ward and bringing Macdonald’s in for some of the other patients. A CMHT member is on the case for housing. Eventually a hostel place is found. She’s discharged. Remember that.
Maria makes a big fuss at the hostel, there’s lots of trouble, it’s not working out. She goes to the CMHT. She’s been discharged. She needs a referral letter. A&E phone the CMHT a couple of hours latter. She’s there. A mild overdose and drunk. They’re very concerned. They want to discharge her to the CMHT. She’s not on the books. Remember that.
A&E need to make a referral. No – they want a psychiatric assessment before she’s discharged. There is no agreement between the Hospital Trust and The Mental Health Trust about who pays for this. Maria can take herself to the Mental Health Assessment Unit when she’s sober. SHO at A&E isn’t happy but has no choice. Sends Maria by ambulance for assessment. Once assessed she is referred to Crisis Team – but she has been discharged from hospital – not mentally ill therefore not eligible. Remember that.
Referral sent on to Psychology, except Psychology only sees people who are mentally ill these days, she’s not for them. Are you remembering?
Referral sent back to Crisis Team. Crisis Team write to GP –Days later the GP phones the CMHT – furious! He wants her seen – pointless ranting, no joy, but routine referral accepted. Maria is discussed in Team Meeting. Decision: this is a not a secondary care case. Needs Primary Care counselling. Outcome fed back to GP, in the full knowledge that there is no Primary Care Mental Health Service because the PCT haven’t commissioned one. Manager explains – “the more we send back the more chance there is they will stump up the cash – this is war!” CMHT starts getting brave – referring back to GP’s with abandon. A stamp is bought – NOT FOR SECONDARY CARE! It is ker-clunked on to GP’s letters and couriered back to them. Team morale is high. The war is being won.
Remember Maria? She is dead of course. Drowned herself in a river. The GP let the Team know, out of anger more than politeness.
“Unprofessional really, to let emotions show like that,” says the Team Manager.
It’s stories like this that make me realise how lucky I am to still have Mr Man.
Mr Man was very nearly discharged after his first 3 weeks in hospital, because like Maria it was thought that he didn’t need to be there, because he put on such a good act.
Thankfully one exceptional nurse took my concerns seriously and informed the psychiatrist on the ward, who in turn took my concerns seriously. Poor Maria didn’t have someone who loved her enough to stay and fight in her corner. It just shows how easily people can slip through the net.
… and if they don’t end up dead they end up doing endless rounds of a&e -> acute ward -> temporary accommodation -> the street -> a&e and so it goes on … or they end up in prison or a forensic unit. if they’re lucky they have the safety net of family and/or good friends. if they’re even luckier, they get decent services – psychotherapy, crisis support, appropriate accommodation.
there are so many marias out there & secondary services just don’t want to touch them – maybe because the potential solutions are expensive and have long waiting lists? because they’re too complex? because the drugs don’t really help? they even find it difficult to get a service in areas where there’s a DH pilot service for personality disorders, if their problems don’t fit into a narrow range that suggests the treatment will be successful.
i’ve met lots of marias over the past few years, and so far, incredibly, just one is dead although i suspect there’ll be more in another few years if things don’t start changing …
Great post.
Was a kick in the teeth, but great post. Not all of those kicks are bad things.
/jo
Interested that you should think that Maria would be diagnosed as Personality Disordered, survivorworker. Any particular reason?
It’s a very sad story and a severe indictment of a society that doesn’t care about, or look after, people who just don’t cope very well. But the idea that Maria should use up scarce mental health resources is really unfair on those of us who have a mental illness and need the specialist skills of psychiatrists etc. There should instead be social welfare services for people who cannot manage their life.
I’m guessing that survivorworker assumed Maria was a PD case because of her chaotic behaviour and because the CMHT didn’t want to touch her.
What was her diagnosis Malcolm?
That’s an interesting point, Ariel. I think the scarcity of resources and the intendant pressure the mental health services was definitely a driver for the “war” and the sense of victory when the CMHT found a justified argument not to take on clients who aren’t quite sick enough. I’m not sure though that mental disorders/psychological problems and social problems can be separated so easily though. There is an argument that nurses should do work centred around health education and illness prevention, to avoid more severe effects emerging.
In cases like these often no formal diagnosis is made, just a load of people sitting around in meetings nodding their heads and rolling their eyes knowingly at each other implying Personality Disorder. PD in this context is, of course, shorthand for “trouble”.
A while back, a friend of mine asked me what the difference was between a mental illness and a personality disorder. I replied, “A personality disorder is the psychiatric equivalent of calling you an arsehole.”
At the time, I thought I was joking. Now I’m not so sure if I was.
I guess I can see the argument that if PD cases tend to soak up the resources of services without seeing much in the way of clinical improvement in return, then maybe the CMHT were justified in not offering Maria a service.
Does that mean that if the CMHT had taken her on, then Maria would have wound up in the river anyway? Hang on, a helpful rep from the Big Pharma Great Satan gave me a Glaxo SmithKline-embossed crystal ball at a drug lunch/channeling of Cthulhu. I’ll just gaze into it to find out the answer to that one…
Ph’nglui mglw’nafh Cthulhu R’lyeh wgah’nagl fhtan…
I find it amazing that we both work for the NHS, this is clearly a case of post code lottery. Where I work there is a clear (though sometimes grey) division between primary and secondary care. Primary care deals with mild to moderate depressions and anxiety, the secondary services deal with serious mental illnesses eg schizophrenia, bi-polar etc and mood disorders of a serious nature where these significantly affect someones day to day living. The secondary services are also involved where any risk is present, regardless of type of mental illness, and this most definitely includes most PD’s.
Part of the secondary mental health services budget is given to the GP’s so that they can provide counsellors/psychologists for their mental health service.
Our district general hospital also has a psychiatric liaison team who see all self harming admissions. Also, we do not ask people to jump through hoops, anyone can refer themselves to the CMHT – they can walk in off the street and they are all entitled to an assessment of their neeed, and signposting on if not appropriate for CMHT.
In the above scenario, granted we do not have all the details, it seems clear that there was nothing in her behaviour on the ward that indicated need to be an inpatient. However I do not accept your point (or rather the Crisis Teams) that because someone is discharged from hospital ergo they are not mentally ill. All it means is that they don’t need hospitalisation.
I think that had Maria been here, she would have been accepted by the CMHT due to her chaotic behaviour, and certainly following her OD. However, I said this is making a lot of assumptions, not having all the facts.
“Interested that you should think that Maria would be diagnosed as Personality Disordered, survivorworker. Any particular reason?”
not that interesting really – it seemed blindingly obvious that that would be the case …
because i’ve worked in mental health services for long enough to know that’s the label people with issues like maria will get stuck with
because i know a lot of people diagnosed with BPD (myself included) and maria’s story could easily be an amalgamation of the stories of 3 or 4 of my friends.
because i have a copy of my medical records and have seen the correspondence between my GP and the CMHT & i’m now wondering whether you broke into my house over the weekend …!
or maybe i’m just very cynical …
zarathustra – looking at it from another angle, maybe the CMHT isn’t offering the right service? it’s all very well treating a flower bed with herbicide, but if the flowers are being eaten by greenfly then it’s not really going to do much good …
CPNurse – I think we have touched on this before, and OSB’s experiences of acute care and mine are completely different. I think that other posts have indicated that they recognise the story. I have I think been either extremely unlucky or just very stupid to have worked in the areas I have worked. One of the great things about this site is learning that Mental Health Services aren’t this bad everywhere. I would so love to name names and tell you the area, but I can tell you that the PCT has not commissioned Primary Mental Health Care services, and the Mental Health Trust has closed their counselling and psychotherapy services down. A neighbouring trust has a team of counsellors who are literally doing nothing while the funding is being agreed. Sounds like your area has done a good job and has…dare I say it…good sensible managers, a crisis team who recognise a crisis when they see it, and a hospital liaison team to intervene (although, when there was one, I even saw referrals from them treated in the same way). Locally the prevailing attitude from the top is one of gatekeeping – and this has naturally spilled down to the practitioners.
My view is, and was, that Maria should have had a service, however a lone voice I’m afraid.
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