One of the challenges of being a professional working in the mental illness/mental health sector is managing experiences of when things don’t go to plan with clients.At other times looking for support from other professionals and being disappointed by their lack luster responses.
My being a black male counsellor/psychotherapist/mental health practitioner in a largely white eurocentric profession has been mostly a rewarding and at times a challenging experience. The following piece of writing looks to examine the difficulties of preconceived notions of mental health professionals. With an aim to observe whom is ‘qualified’ to ascertain what, if any, treatment could be given to whom, and what reasons there may be for suggestions offered.
New Role – Collaboration
I am currently (Aug 2016) working in the London borough of Southwark as a member of the IOM team (Integrated Offender Management) as a Forensic Mental Health Practitioner for Together. The IOM team comprise of Offender Managers (OMs) from Probation, Housing Officers from St Mungo’s, Lifeline practitioners (Drugs and Alcohol advice and support) and the Police. The idea is to form a collaborative approach for the service user being supported. My role looks to establish robust links with mental health services in Southwark and work closely with service users providing access to mental health services.
My new role is a slight departure for me. Previously I supported 5-6 Probation Offices from April 2015 – July 2016. The former NPS role (National Probation Service) involved me being in a different probation office from Monday – Friday. I covered NPS offices between a number of London boroughs including Greenwich, Merton and Bromley.
Working as a counsellor in a prison from October 2010 – December 2014, I applied a carousel way of working in that I went to where clients were to support their requests for psychological therapies. I visited ‘Houseblocks’ (where clients ‘lived’), Education departments, Work Shop and the Kitchens to engage clients with psycho therapeutic work. Practicing working in this way was challenging. Clients that had been previously assessed as wanting to access psychological support could when met in workshop or in Education flatly refuse to engage. Others did not seem to mind the environment they were in to engage with the work.
Support to colleagues
Back to my new role in Southwark. A colleague, at the Southwark office, had asked my opinion on a former gang member whose case they were working on. Mr Waters (Not the Clients name) had been a victim of a bladed attack. I suggested that he may have possible PTSD symptoms or complex levels of trauma. My suggestion also included that he may need a highly specialised form of psychologically informed treatment to support him.
The Assault and consequences
Mr Waters had experienced the attack when he was in his 20’s and had almost died from his wounds. The assault had come from known assailants. Difficulties for him arise when he drinks. From my colleagues account it is like he reverts back to the person he was in his 20s – seeking revenge for his pain, shame and anger at suffering the surprise attack.
My suggestions involved either EMDR (Eye Movement Desensitisation Reprocessing) or trauma focused/ trauma informed CBT to assist Mr Waters re-conceptualising his life. A.S. the colleague who had made the enquiry, found the information we had discussed useful. The court report would offer comprehensive recommendations to address his alcohol intake and desist from drug use and to engage in psychological support to address his underlying issues.
My next step was to locate services in the home borough that Mr Waters could be returning to, and where I thought he could access support from. I contacted a fellow FMHP who knew of services in Mr Waters home borough, with an aim to gather a few numbers to make enquiries of mental health services.
Ms Tiller – a barrier?
I was able to contact 2 psychological services, IAPT and a collective of counsellors and psychologists practicing from one location. Of the 2 services I was able to engage with one service which was an IAPT service (Increased Access to Psychological Therapies) of the borough in question. After explaining to the 1st person who answered the phone what I was calling for I was transferred to a senior psychotherapist.
I shared that I was calling as a Forensic Mental Health Practitioner working in the London Borough of Southwark. ‘The reason for my call was to inquire if the borough in question had a psychological service that could treat a person with complex trauma with either trauma focused CBT or EMDR?’
Ms Tiller (Not the Psychotherapists name) asked how I knew that this person would require either CBT or EMDR? I explained a little more about Mr Waters case and some of Mr Waters presenting issues. Their response was simply that clients with extensive drug dependency issues and alcohol addictions as well as long criminal histories would not be suitable for their service. On all three counts Mr Waters was untreatable by this particular IAPT service, is what I heard.
Where to go for support?
I began to get heated as her refusal seemed unfair and I explored that if the IAPT service could not support a service user of probation and possibly soon to be released Mr Waters then the system did not appear supportive to Mr Waters or to people like him or to the communities that he could live amongst. I also explained that Mr Waters had stopped using both alcohol and drugs and had maintained a non-dependent relationship for over 2 years. Ms Tiller said that Mr Waters would not be suitable and that I would need to find another service. The IAPT service I called do not offer EMDR or trauma focused CBT in any event. Either the Portman Clinic or the Tavistock might be able to offer some support Ms Tiller eventually offered.
Level 3 or 4 support
What Ms Tiller did not fully explain was that due to Mr Waters complex set of circumstances he was too complicated a client for that IAPT service. What Mr Waters would need was a higher level of support tailored to the range of interlinking set of difficulties he has.
The experience of almost losing his life by those he had trusted may have come as a considerable shock. To cope with this realisation it is possible that drinking alcohol and taking class A drugs may have helped to stabilize and suppress unwanted images, fear reactions of other experiences of shock and let down. Leaving familiar surroundings and starting a new life in another city (London) may have brought a sense of relief and a sense of fear which may have continued the drinking and drug habit. 15 – 20 years later with a number of prison sentences for ABH, GBH common assault and with failing health Mr Waters may have come to a realisation that living as he is (surviving) could not be continue. It may have been at this point and facing another term incarcerated that may have shaken him into realisation that something was not working anymore.
Key Facts from the experience with Ms Tiller and IAPT.
- IAPT services in this particular London Borough appear unwilling to support forensic clients.
- IAPT in this London Borough either do not have the resources ot are unwilling to offer complex clients CBT
- IAPT in this London Borough have staff that are unconsciously prejudiced or scared or both to offer forensic populations potentially life-saving support.
- The Portman or Tavistock may be able to offer support to Mr Waters and clients like him with the support they could find potentially life altering.
- Had Ms Tiller had the patience to listen she may have heard that I was looking to locate a service that Mr Waters could attend to access the specialist support he needed.
- As a qualified counsellor perhaps using the term practitioner in situations where I am speaking with a peer, psychotherapists like Ms Tiller may be able to step aside of their pre-judgements and actually hear what clients and other professionals are sharing with them.
As a Black male counsellor/psychotherapist I am able to view both myself and others in relation to the work. I am offered ample chance to be reflective of numerous interactions and review that being black was not a feature in Ms Tillers dismissal of my suggestions. It is also possible that her dismissal came from believing that I was a practitioner and had no appropriate experience to even guess that Mr Waters could be suffering from PTSD symptoms.
Mr Water’s presentation in the last 15-20 years which possibly were exacerbated through self-medication with alcohol and drug taking. Also involving himself in high risk activities (Gangs) possibly added to his set of difficulties. Mr Waters becoming violent at the slightest provocation could make him present as highly difficult to engage with in a statutory setting. I wonder where else could Mr Waters access state sponsored mental health support?
An Act of Patience
My argument to Ms Tiller is that with a small amount of patience in handling a request for information, could have assisted her in arriving at conclusions that were made in haste not reflective and were restrictive in their proposals. Ms Tiller also did not appear to offer a collaborative approach to arrive at a possible solution with me, a peer.
What frustrated me most was Ms Tiller’s near panicked, confused, rejection of a possible referral to the service she supports. There appears to be an apparent need for IAPT services to also be informed of who could benefit from NHS IAPT guidelines of stepped care support. Where possible clients that are beyond step 3 be offered alternative support from specialist services like SLaM, St Georges Trauma Therapy Centre and The Bracton Centre
If all IAPT services are either A, unwilling or B, unable due to lack of resources to support forensic clients, a misrepresented section of the community that could access psychological support will unfortunately miss an opportunity to begin reviewing change in their lives and have the potential to work on rehabilitation within their communities.
When a service user becomes motivated in prison to begin working on some of their concerns and start a piece of psychological work is a significant step towards change. Aspects of their lives i.e. root causes of various problematic behaviours and presentations could then be understood for further psychological input once released. The grounding of prison based psychological support could then be continued in the community to assist with the service users re-integration, readjustment and realignment of the individual to their community and the community to them.
Training for Staff
I feel that there is an urgent need to educate the forensic system also. The aim here would be to better support service users in forensic institutions like Police Stations, Prisons, Courts and prisoner Transport vehicles. Once service users leave prisons, in community support could be better facilitated to accept and to treat willing clients. Currently the system falls down as illustrated by the example of Ms Tiller.
The current system of support once a service user leaves a prison, is for them to access Probation services either NPS (National Probation Service) or CRC (Community Rehabiltation Company) depending on the severity of the offence committed and type of supervision the service user can access. Probation officers are highly skilled and trained to offer support to their service users. An additional consideration and training could be offered to address mental illness with the aim of equipping offender managers and probation officers with some psychological tools to assuage the rehabilitation process.
Services like Together, DePaul Charity and RAPt offer an important step in providing forensic populations with support. Accessing a stepped care system that the NHS adopts for clients who request mental health support is a programme that is currently being developed by Together in London. The aim of a Forensic Mental Health Practitioner working in Courts, Police Stations, Liaison and Diversion (L+D), NPS, IOM, SAVU (Southwark Anti Violence Unit), and GTO (Gripping The Offender) is to provide robust brief therapeutic support to service users and where possible to refer them on to services like IAPT or acute/specialist services for additional support.
After my experience with Ms Tiller I am confirmed in my view that entering and leaving prison could have more joined up thinking in providing service users with ongoing psychological support if requested. The aim would be to invite services like the one Ms Tiller supports to form a safety net with agencies that support service users for all future clients.