How can Independent Mental Health Advocacy help you?

Last summer we featured Connecting with the mental health advocates in which we found out more about the three different advocacy roles in Powys, and met some of the advocates themselves – in particular those based in Powys. 

Today we talk to Adrianne Cleverly, who works for Conwy & Denbighshire Mental Health Advocacy Services, but actually provides an advocacy service for Powys (which is commissioned by Powys Teaching Health Board). I met Adrianne earlier this year, and we all agreed it was important to try to raise awareness of the advocacy service available in the county.

Tell us what brought you to work in the field of mental health advocacy?

I was fortunate enough, and lucky enough, to fall into the field of mental health advocacy – by complete accident. I was working in child protection; within that role I was working with Child and Adolescent Mental Health Services (CAMHS) and acting as an advocate for some of the children I was working with. The role was so varied that my experiences spread further than I had even realised because when you are doing the job you take those things forgranted and just get on with it. One day someone showed me the job advert for an IMHA (Independent Mental Health Advocate). When I read the job specification, I could not believe a job like this existed. I applied for the job, and what can I say, three years later, I still love the role and still feel lucky enough to work in this position. I love my job! You definitely have job satisfaction when you work as an IMHA. Sometimes the differences you make can seem trivial but the difference you are making to the person is so much more. It is such a rewarding job.

What is your role at CADMHAS and which area do you cover?

My role at CADMHAS is an Independent Mental Health Advocate. Within this role I cover the South Powys hospitals - Ystradgynlais, Bronllys and Brecon. Within the role of IMHA my role means that I visit the hospital wards and meet with qualifying patients (people admitted to hospital for their mental health). I work with them within the remit of accessing their rights under the Mental Health Act and support them with anything to do with medication, treatment and care.

I also deliver awareness raising sessions in North Powys. Those hospitals are Phoenix House, Welshpool, Machynlleth, Newtown, Knighton, Llanidloes and Llandrindod. As part of awareness raising I also work with the community mental health teams which are Ty Illtyd and The Hazels, additionally other professionals that might also be working with the same people as myself, should the scenario require me to.

Many people don’t know about the advocacy service. What are the key benefits of having an advocate?

The benefits of having an advocate will vary for the individual and depend on why they felt they needed/wanted an advocate in the first place. For some people they may have more than one admission to a hospital ward and they may want an advocate on one visit and not another. The beauty of the role is that it is led by the individual. It is not the choice of the professionals or the family, but the choice of the individual.

One main benefit of having an advocate is to ensure that you have a voice when you need it. Also the reassurance of knowing that someone is making sure your voice is heard. Other benefits include empowerment to have a voice. Receiving the knowledge and understanding and being helped and supported to understand your rights when you are in hospital or having some experience of the Mental Health Act (maybe living in the community but being on a Community Treatment Order or Guardianship). Also, having the availability to access those rights. Additional benefits are to feel supported by an independent professional and feeling like someone is on your side.

What key qualities does a good mental health advocate need to have?

The qualities of a good mental health advocate are simple; they will be non-judgemental and listen to what the person is actually saying. An advocate needs to be a good listener, they will be well informed and skilful. They will have confidence in themselves and be comfortable enough to stand up for the person’s rights.

Just for clarity, can you very briefly summarise the three different mental health advocacy roles?

Independent Mental Health Advocate 

An Independent Mental Health Advocacy (IMHA) means the qualifying patient has access to an IMHA which is a statutory right for people detained under most sections of the Mental Health Act, subject to Guardianship or on a community treatment order (CTO). When someone is detained in hospital or on a CTO it can be a very confusing and distressing experience. 

Independent Mental Capacity Advocate 

An Independent Mental Capacity Advocate is available to everyone surrounding the care, treatment and support of people aged 16 and over living in England and Wales who lacks capacity to make all or some decisions for themselves in specific areas. These areas being change in accommodation, care reviews, safeguarding issues and serious medical treatment. An IMCA will also be involved in those detained under a Deprivation of Liberty order. The Mental Capacity Act is designed to protect and restore power to those vulnerable people who lack capacity. 

Community Mental Health Advocate 

Community Mental Health Advocates provide and offer representation and support at meetings and appointments to people who have been treated for their mental health and are now living in the community. An advocate is someone who will listen to your worries and problems and work alongside you to achieve your aims. Advocates are a valuable source of information and can help the people who use their service to feel in control of their own lives – to feel empowered. 

Can an individual be supported by all three types of advocate at once – IMHA, IMCA and Community Mental Health advocate? If so how does that work?

Yes an individual can be supported by all three advocates. All advocates work in different ways so if a person needs support in different areas they will be eligible for different advocates. An IMHA will work with an individual within the remit of medication, treatment and care.

An example of this would be if a patient is on a Community Treatment Order they will be eligible for the support of an IMHA who will support the individual with representation at a managers' hearing or tribunal. They may also have been deemed to lack the capacity to make a decision on their placement so they will then be eligible to have the support of an IMCA as IMCAs will work with the individual around this. They then might need support with things like pension and finances, so they will then require the support of a community mental health advocate.

What happens when a carer refers but the patient/individual does not want to engage?

This goes to the heart of advocacy. The individual is the one that instructs the advocate and decides if they want to work with us. If a person has capacity to understand the role of an IMHA and they don’t want an advocate that is their choice we would not force ourselves on them. The work of an IMHA is client led. If the individual doesn’t want to work with an IMHA, we cannot make them. We can ensure that we give them plenty of choices and just be available for them if they change their mind.

If the person does not have capacity then we can still work with them, but it will be in a non-instructed way. This means that we work with the family and professionals to establish as much information as we can and then work in the person’s best interest.

If someone is placed in a hospital or unit outside Powys, can you still support them? 

Usually our role would stop but we would signpost to other agencies.

If a patient is placed on a Community Treatment Order (CTO) what support can you provide as an advocate?

If a patient is placed on a community treatment order, our role would remain the same as if we were visiting them in hospital, but we would visit them in the community instead. We would still work with them around their medication, treatment and care and we would also attend meetings with them around these themes. We would also still support them with their rights under the mental health act and support them at managers' meeting and appeals.

Which organisations do you work most closely with in Powys? 

As an advocate in Powys there are quite a few organisations we have worked with. The main people we work with are Social Services and Community Mental Health teams. Additionally we also work with organisations like Age Cymru and the Alzheimers Society. We also work with the ward staff, and Best Interest Assessors.

What are the main challenges of your role?

Some of the main challenges experienced are having the ability to manage the expectations of not only the client but also their family. Another challenge is when delays happen and it is completely out of our control but there is an expectation on us to make it happen. Another challenge would be the conflict of interest and other people’s understanding of our role, including professionals.

Tell us about some of the most rewarding work you have done so far with CADMHAS?

For me personally, the most rewarding part of my job is when the client gets what they want! Especially when the work started it was not even a possibility, knowing that you have made that difference to that person. This includes things like making sure the clients are listened to and that there is communication between staff and patients.

When you are not working for CADMHAS, how do you enjoy spending your time?

I love to spend time with my family, doing things like mountain biking, surfing and walking. I enjoy listening to music, reading and cooking. It sounds a bit cliché but I love the ‘normality’ and chaos of family life! 

Many thanks to Adrianne for telling us all about her work as a mental health advocate. If you want to find out more you can contact the Powys Independent Mental Health Advocacy Service managed by CADMHAS by emailing admin@cadmhas.co.uk or ringing 01745 816501.

Connecting with the mental health advocates

Powys mental health advocates Kirstie Morgan and Lynda Evans

“Advocacy”, it says on a whiteboard opposite my desk, is “taking action to help people: say what they want, secure their rights, and obtain the services they need.”

Many are the times I have signposted people calling our Information Service to the mental health advocates working in Powys. Last week two of them, Lynda Evans (North Powys), and Kirstie Morgan (South Powys), came along to the July team meeting of the PAVO Community Connectors to update them about the advocacy services available in the county. I was lucky enough to join them, and this is what we found out.

The three different advocacy roles in Powys

Independent Mental Health Advocate

This role was introduced in 2007 when the Mental Health Act was revised and advocacy was put on the statute books. Advocates suddenly had rights which they had not enjoyed before, such as advocating for mental health patients in hospital, on a Community Treatment Order, or detained under the Mental Health Act.

The provision is much broader in Wales than in England. Anyone in a hospital bed in Wales who is being treated for a mental health “disorder” is entitled to a mental health advocate. The IMHA can support someone who wants to challenge, for example, their detention under a Section 3 of the MHA.

IMHAs can also go into a ward and observe a patient’s treatment and interactions with staff – they cannot be prevented from doing so except in extreme circumstances – such as if the client is unwell and may present a danger to the advocate. IMHAs may, in addition, interview psychiatrists and social workers in private, access the medical notes with permission and share information with the client.

With her IMHA hat on Lynda ensures that proper process is followed, and that a person’s rights are upheld. “If a patient is told they can’t have leave because they’ve not been good, that is punishment. They can’t do that. There has to be a clinical reason to stop leave.” In another situation, a patient who is not being detained under a section may be told that they will be detained if they don’t behave. “This is wrong and totally illegal. Our job is to challenge on behalf of a patient. The first loyalty is always to the client/patient”.

Independent Mental Capacity Advocate

The Mental Capacity Act 2005 introduced the role of the Independent Mental Capacity Advocate. An IMCA is instructed either by Health or Social Services, not by the patient as they lack capacity. The lack of capacity may be due to a brain injury, mental health issues or dementia. IMCAs can be called on when treatment is about to start or to be withdrawn, and the patient has no family or friends who can be consulted. Or, there could be safeguarding issues which mean that it is not appropriate for the family to act on the best interests of the client.

An IMCA has many roles, including:

1. To support the client whilst a Deprivation of Liberty Safeguards assessment is made. The Alzheimer’s Society states that: “If a care home or hospital plans to deprive a person of their liberty… they must get permission. To do this, they must follow strict processes called the Deprivation of Liberty Safeguards (DoLS). DoLS are a set of checks that are designed to ensure that a person who is deprived of their liberty is protected, and that this course of action is both appropriate and in the person’s best interests.” So, for example, when rehousing someone in a nursing home it is important to consider a person’s preferences (they may previously have preferred the countryside to the town).
2. To support a family member who feels overwhelmed by the whole process of being the “relevant person’s representative” – who must be kept informed about the person’s care and treatment and any changes to it.
3. To visit the nursing home once a month to make sure all is as it should be. 

Community Mental Health Advocate

People in contact with statutory mental health services from age 18 and over in Powys are entitled to receive support from a Community MH Advocate if they wish. Those in receipt of local primary mental health support services (ie: through a GP surgery) have to be screened first as so many people seek support for mental distress from a GP.

The majority of the work in this area is for people supported by secondary mental health such as Community Mental Health Teams and Crisis Resolution & Home Treatment Teams. Kirstie explained that the work is vast and varied. The work could be long or short-term depending on the situation or the nature of the issue. “Quite often people are very poorly before they come to us and have to address a number of issues.”

Clients can self-refer, be referred by a relative or the voluntary sector (Mind centres or Ponthafren Association for example), or via the Community Mental Health Teams. “People see advocates when everything has gone wrong. In cases where the individuals have a dual diagnosis and their mental health is the prominent issue we will advocate. We work alongside many projects and advocacy schemes in Powys. Our aim is to build a good rapport and understanding with the client and there is a high level of professional trust.”

People have an entitlement under the Mental Health Measure (Wales) to access the CMHT duty desk and regain entry to services within 3 years. Advocates can support clients with this process.

Appropriate Adults

Kirstie and Lynda will also sometimes act as Appropriate Adults at police stations in the county to support and advise vulnerable people known to advocacy in police custody. The mental health charity Hafal is the main provider of Appropriate Adults in Powys.

A bit more about our Powys advocates

Lynda has been an advocate for 14 years now She is employed by Powys Teaching Health Board to be an IMCA and a community advocate, and for a small number of hours a week by Conwy & Denbighshire Mental Health Advocacy Service to be an IMHA in North Powys. Her current base is Fan Gorau at the Montgomery County Infirmary in Newtown, tel: 07736 120 924.

Kirstie is employed as a Community Mental Health Advocate by Powys Teaching Health Board, and provides advocacy in Mid and South Powys. She has worked in the field for 13 years now and is currently based at Neuadd Brycheiniog in Brecon, tel: 01874 615996 or mobile: 07967 808 145.

Linda Woodward also provides IMCA services across the county, and community advocacy for over 65s in North Powys. She is based with Lynda at Fan Gorau and can be contacted on 07974 935 355.

CADMHAS employs three other advocates in Powys – John Curtis in the North, and Adrianne Cleverly and Jane Wazir cover the South. You can contact them by ringing: 01745 816501.

You don't have to be mad to work here, but...

Carla Rosenthal recently joined the mental health team at PAVO to provide maternity cover for Angharad Griffiths. Some readers may know her from her previous role as editor of Headspace magazine for Powys Mental Health Alliance. During that time she organised some very interesting Open Days throughout the county.

Carla has thrown herself with great enthusiasm into her new role at PAVO; you can watch a video of her first Coffee Moaning, which took place in Knighton in May. She works very closely with Anne Woods, a participation colleague focusing on the Stand up! for emotional health & wellbeing project funded by Comic Relief.

With one of her many other hats on Carla is also a Mental Health Act Manager in North Powys. We spoke to Carla at her Llandrindod base to find out more.

Tell us more about your new role in the PAVO mental health team

The job title is Participation Officer and essentially it’s all about community engagement. I spend a lot of time meeting people and talking about Mental Health Services in Powys. All views, opinions and issues are collated and then given to Individual Representatives who take the grassroots voices to Board Level. I grab every opportunity to talk to service users, carers and third sector organisations to discover what is working well and what needs bringing to the attention of the health board and other mental health service providers. And I’m busy organising Coffee Moanings around Powys. (The next one is in Ystradgynlais Library on Friday 7th October 10.30 - 12.30 in the Wedding Room).

How is the new job going so far?

Four months in and I’m busier than ever! Along with supporting Individual Reps, attending Patients' Council at Bronllys Hospital, talking to people at events, and writing emails, there are lots of meetings to attend and new contacts to follow up. When I’m not travelling around Powys, I’m getting used to working in an office (a new experience for me) and I really enjoy the work I do - there’s never a dull moment.

Why should people who have been in contact with services come along to a Coffee Moaning, or a Stand Up! for emotional health & wellbeing session?

The aim of these events is for ANYONE who has interest and experience in mental health services to come along and get their voice heard. The evidence that’s gathered from these events is gold dust to the Individual Representatives who work closely with service providers such as Powys Teaching Health Board and partners on the board like the Police and the Council. It is imperative for those who plan services to hear what is needed from the people who actually use the services.

I believe you are currently looking for people to become new Individual Representatives for the Powys and National Boards. Can you tell us more?

Individual Reps are the voice of the people - it is thanks to them that service users and carers are represented. It’s an opportunity for anyone passionate about planning and developing mental health services to get involved and feel that they are helping to make a difference. Although it is a volunteer role, travel expenses are paid and there’s a fantastic training package being put together which equips Individual Reps to feel confident at strategic board level meetings. 

The partnership meetings are held every two months and there are opportunities to sit on sub-groups which are instrumental in delivering the Mental Health Strategy for Wales. Should an Individual Rep wish to attend the National Partnership Board, I assist in liaising with the Mental Health Foundation who appoint the National Reps and there are National Forums where all the Reps from across Wales get together to share information and good practice.

PAVO's mental health team with Seat 35, L:R - Jane, Anne, Jackie and Carla

What about your other role as a Mental Health Act Manager for Phoenix House Hospital in Welshpool? Tell us about that.

Mental Health Act Managers meet when an in-patient has requested an appeal hearing against their section. The title ‘Manager’ is somewhat misleading as we are all lay-people and come from a variety of backgrounds. My interest is this role came about due to having been a patient under section at a hospital in Surrey several years ago along with a brief spell in Bronllys. I can see things from the perspective of the patient as well as from a professional viewpoint.

As Managers, three of us meet before the hearing and read through the reports compiled by psychiatrists, doctors, lawyers, social workers, nurses etc. We then make a particular point of having an informal chat with the patient first, to help put them at ease and give them the opportunity to put their side across before everyone comes in. The hearing itself can be rather daunting as all professionals involved come together to give their opinion of the future care of the patient. When we have heard everything from everybody and the room has been emptied, we make a decision based on all the evidence presented.

To be held under the Mental Health Act, an individual is deemed to be at harm to self or others and needing treatment in a place of safety to prevent harm happening. If, as managers, we feel that the patient has received appropriate care and treatment and has recovered fully to become a ‘voluntary’ patient and/or even leave hospital straight away, we can lift the section. However, some people need to continue their treatment before they can be released and we then look at how they can work towards becoming a voluntary in-patient. We talk to the outside agencies such as community psychiatric nurses and social workers about what care will be put in place for when the patient leaves hospital. It’s an extremely important and responsible decision which cannot be taken lightly. Having been a patient, I understand how difficult a hospital stay can be but I’m also aware of what it’s like to be ill and needing care. Ultimately, the patient’s welfare is at the heart of our decision.

How did you get involved at Phoenix House?

When I was magazine editor of HeadSpace, I wrote a feature article on Phoenix House and one of my contacts there told me about the Managers' Panel and suggested I applied for the role. I had to complete an application form and have a formal interview before being given the position. In nearly two years, I think I’ve attended 6 hearings.

What qualities should a good MH Act Manager have and why?

As I mentioned earlier, the decisions we make have a direct and immediate impact on a patient and that responsibility is not to be taken lightly. Compassion, understanding and the ability to listen and read through a variety of evidence is essential along with a sound knowledge of the Mental Health Act and maintaining confidentiality. Along with these professional skills, a good Manager is one who genuinely listens to the patient and those working with them because whilst reports have their place, the conversations that happen during the hearing are the key to making the final decision. The Managers are aware that it is quite an emotional and stressful event for the patient and our behaviour and communication needs to reflect this during the hearing. A smile goes a long way :-)

Have you sat on an appeal panel which has discharged a patient from a section? What did it feel like?

Yes, I have and the emotions are mixed. Although seemingly a positive outcome, sometimes you get the feeling that this person is going to need support for while and although not needing a hospital setting, the willingness to engage with outside services has to be there in order for that person to thrive. I’ve worked with people who when they are in hospital they’re aiming for release, but when they’re back at home there’s nothing to aim for and they find themselves relapsing.

If during an appeal panel a patient is discharged from a section, what support has to be in place for the person?

From the moment of discharge, a patient’s status becomes ‘voluntary’ and they are free to leave. Sometimes, the section will be lifted on the proviso (agreed with patient and staff) that they stay for maybe an extra week in order for housing or a support service to be sorted out. In reality, lifting a section is only dependent on a person’s likelihood of harm to self or others so housing, support networks etc, are not part of that decision. However, our duty of care is such that we try to ensure that everyone involved is ready to provide the support as soon as possible.

What are the main challenges of the role?

This directly links with the previous question as there was a situation when if the patient was discharged, they would immediately leave the hospital into unsuitable accommodation and continue a lifestyle which had contributed to their initial ill health; however, there was no legal case to maintain the section. It’s times like this that the panel needs to consider very carefully the future of the individual. It’s all too easy to see a yo-yo effect of the same faces re-appearing in hospital but at the same time, we can’t keep someone detained in hospital just because on their release they want to go down the pub and have a beer and a fag!

Tell us about some of the most rewarding work you have done in the mental health field

On a personal level, I really enjoy going to Felindre Ward at Bronllys Hospital because some of the staff remember me from when I stayed there in 2011. It’s an amazing feeling when I can sit with patients in a Patients' Council meeting and say, I understand, I’ve been here too.

Recently I met some people at the PAVO offices who wanted to discuss a family member’s mental health. I sat across a desk telling them, “It’s ok, I’ve been in the same head-space that your family member is in and my mum has been in a similar situation to the one you’ve found yourselves in.” We all shed some tears. I signposted them to a variety of organisations, offered personal support and generally empathized. They were so reassured that just because someone is experiencing mental ill health, options don’t close down (as some people still think), instead options will open up.

And I still joke about my job: “You don’t have to be mad to work here - but if you put it on your CV, it’s a bonus”.

When you’re not working how do you enjoy spending your time?

I adore reading and devour books from the library - a day without my book time is not good! I’m also studying a Royal Horticultural Society course in horticulture and really enjoy gardening but a recent house move means most spare time is spent unpacking boxes I haven’t quite got round to yet . . . and I’ve got kids and dogs and horrible housework!

Many thanks to Carla for telling us about her various roles. If you would like to find out more about Coffee Moanings, or becoming an Individual Rep, just contact Carla by ringing 01597 822191 or emailing carla.rosenthal@pavo.org.uk

Dyfed Powys Police - Mental Health : Working Together - Part 2

We found out in Part 1 of this post last week how Dyfed Powys Police has been rolling out mental health awareness training sessions for the force's staff and partner organisations over the past few months. I was lucky enough to be able to attend the May session as the PAVO representative. These sessions have focused specifically on Section 136 of the Mental Health Act 1983, and the collaborative nature of the approach to this 72 hour detention which can be instigated by the police. 

The first half of our training covered a look at our needs and expectations, an introduction from the police mental health lead Inspector Brian Jones, setting of context by Lousia Kerr who is Powys Mental Health Partnership and Project Manager, and a consideration of "what is mental health?" by Powys psychiatrist Stephen Novick. Kath Arnold, manager of the Integrated Community Mental Health Team in Brecon, was next up before we ran out of space. In Part 2 we complete the picture. 

Approved Mental Health Professional – Helen Kiteley, Social Worker PCC

Helen described the very specific role of the Approved Mental Health Professional – a social worker who is specially trained to consider when someone may need compulsory admission under the Mental Health Act. “The AMHP is tasked with balancing care v control in the context of managing risk and the Human Rights Act 1998”.

This does not necessarily mean that someone ends up in hospital. They could be managed by the Home Treatment Team (more below) and able to stay at home. The “least restrictive intervention” is the one which has to be used.

Helen also covered a Section 135, the role of the “nearest relative”, and a AMHP’s duty to complete Mental Health Act assessments when required.

Crisis Resolution Home Treatment Teams – Andrew Williams (South), Graham Batha (North)

Andrew Williams

Andrew explained that he was a man with two hats! With his Welsh Government hat on it is his statutory responsibility to gate-keep admissions to hospital, to respond to crisis referrals in 4 hours and review out-of-hours referrals in 24 hours. With his practical hat on Andrew and his team are providing individuals with intensive support in their own homes. Staff work closely with family members and friends to maximise levels of support, and provide psychological and practical help. “Crisis prevention is really key.”

Graham’s view from the North of the county was not dissimilar. He said “we bring many aspects of hospital care to the patient’s home. Currently we have 300 patient contacts per month.”

Both teams work out of hours, though not 24/7. You can read more about the work of the North Powys HTT here.

Brian highlighted the fact that the police are operating in a different place to that of just 2 years ago. “As soon as we are facing a S136 we go out to someone who may harm themselves. But the HTT now arrive and say the police can leave”.

Graham Batha

Felindre Ward, Bronllys Hospital – Richard Rudge, Deputy Ward Manager

Felindre Ward is the designated Place of Safety for Mid and South Powys (except Ystradgynlais) where people can be taken by the police on a S136 for a mental health assessment. Richard talked us through the 12 bedded In-Patient Unit, the specific roles of staff based there, the admissions procedure and then in more detail the role of the nurse in the S136 process.

The team at Felindre works very closely with CMHT teams at Brecon and Llandrindod Wells, as well as the South Powys CRHTT.

Some interesting questions emerged during this session, such as what happens when someone is visiting Powys and is detained on a S136. It was clarified that they are then brought to a Place of Safety within Powys to be assessed, rather than being transported back to where they originally came from.

Emergency Duty Team – Debbie Everett, Social Worker & Michael Dalladay Senior Practitioner EDT

“It is the responsibility of the EDT to respond to social care emergencies where the urgency of the situation requires action at a time when mainstream services are not available.” The team has many varied duties, including undertaking mental health assessments.

Experience of someone in contact with mental health services – Jan Rogers

Regular readers of this blog will no doubt be familiar with Jan Rogers (volunteer and trustee at Ponthafren Association, and now MBE!) who then told her personal story. Jan included her experience of being detained under a Section 136 over 30 times, and her subsequent role in 2014 as a member of the Expert Reference Group which reviewed the Mental Health Act 1983 Code of Practice ( in England).

Jan concluded by saying: "things are not always what they seem. Think before making a decision or acting."

Brian rounded off the day with a number of typical scenarios, some of which we addressed in groups. There was some really useful discussion with partners from all sectors contributing and it was clear that the awareness raising had been of genuine benefit to all concerned. My feeling is that everyone working or volunteering in the field of mental health in Powys would find this session invaluable - long may it remain available to enhance our knowledge and encourage enthusiastic partnership working!

Dyfed Powys Police - Mental Health : Working Together - Part 1

Karen Clarke and Jason Hawkins - Police Community Support Officers in Brecon

Section 136
If it appears to a police officer that you as a person in a public place are:
 “suffering from mental disorder” and are: “in need of immediate care or control”, he or she can take you to a place of safety. 

You will be kept in hospital, or the place of safety you were taken to, so that you can be examined by a doctor and interviewed by an approved mental health professional and any necessary arrangements can be made for your treatment or care.  Mind – About Sectioning.

Over the past six months, Dyfed Powys Police has held regular mental health awareness training sessions for staff and partner organisations in Powys. As PAVO’s representative on the Section 136 sub-group, which was set up to reduce the inappropriate use of Section 136 of the Mental Health Act 1983, I was invited to attend. 

So it was in May I found myself at the Combined Services Centre in Llandrindod Wells with a room packed full of professionals from the Police, Powys Teaching Health Board, Powys County Council, Welsh Ambulance Service and a number of voluntary sector organisations, all gathered to learn more about Section 136. And, specifically, the role of the various agencies involved in working collaboratively to ensure appropriate and sensitive detentions occurred in the county.

It was a really interesting day. Packed full of information and just putting names to faces was invaluable. So it was agreed I could share with a wider audience, albeit very briefly, some of the content from the key speakers, and also highlight the extent of the collaborative nature of this work. 

 

Inspector Brian Jones (photo left), the mental health lead with Dyfed Powys Police, facilitated the session. He updated us on this blog last year about a pilot project in Powys requiring the Police Inspector’s authority before police mental health powers can be used. 

Partnership working – Louisa Kerr (photo right), Mental Health Partnership and Project Manager, PTHB

Louisa outlined the legal framework for delivery of mental health services in Powys, which is overseen by the Powys Mental Health Planning & Development Partnership. Its goal is: “to unlock the benefits of wellbeing in terms of physical health, educational attainment, employment and emotional security”.

Multi-agency partners – Brian Jones, Inspector Dyfed Powys Police

When a person is in crisis, it is increasingly the case that the first port of call – whether it be that person, a friend, family member, stranger or organisation that makes the call – is the police.

Brian spoke about the S136 protocol, incident reviews, the challenge of Powys’s geography, data collection, and his key responsibility as an Inspector with powers to authorise the use of S136. As taking away someone’s liberty is such a serious thing to do there is a lot of work looking for alternative options before a S136 is used. For example, someone could stay with family or friends overnight and then a better option be found the following morning. “Now it is a last resort to use a S136. It was much more usual in the past. (We are talking about) a patient that is not well. Going into custody or out of the area is not the best option.” 

Brian threw a question to the floor: “Why do we need mental health awareness training?” The responses included these comments: 

• We want to know how we can best work with people we come across. We want to put them in the right direction. 
• It is about recognising the problem and realising that partnership organisations are out there. 
• There is a lot more openness and honesty about mental health now and this is a major plus. 
• To improve the partnership approach. To talk to each other more – to look at the bigger picture. We are all working to the same end. 
• We are hoping to achieve a better understanding of what our individual roles are. 
• To find out how we fit in and can support each other. 
• For a better understanding of the S136 process and how it might impact on people we work with. 

The rest of the day was spent looking in more depth at the individual roles of specific agencies and mental health professionals.

What is mental health? – Stephen Novick, Consultant in Adult Psychiatry

Stephen began by telling us about the Rosenhan Experiment from 1973 – “on being sane in insane places”. It proved that it is extremely hard to diagnose mental health illnesses.

“Many people who commit suicide are not known to mental health services or mentally ill. Mental health problem sounds better. Mental health illness suggests some people get it and some don’t. Anyone can have a mental health problem.”

Stephen ran through some of the disorders listed in the Diagnostic and Statistical Manual of Mental Disorders, (a diagnostic manual from the United States). However, he said there was very little in the way of hard science except in relation to dementia. “Look at the symptoms, signs, behaviours… what else – drugs and alcohol.”

“People believe all sorts of weird things, but that does not mean they are ill. If they are behaving oddly, it may be a cultural thing.”

With this level of uncertainty around defining mental disorder, it’s not surprising that professionals from different agencies are called upon to agree that certain detentions (sections) are necessary before they go ahead. Stephen went on to describe scenarios when a S136 could be used by the police for a 72 hour detention at a “place of safety”, and to clarify the difference between Sections 2 and 3. 

Brian emphasised at this point that the role of the police is “the protection of life. There’s no getting away from that.”

Community Mental Health team – Kath Arnold, Integrated CMHT manager, Brecon

Kath introduced us to the many and varied roles of professionals employed in the CMHT, including psychiatrists, community psychiatric nurses, social workers, occupational therapists, support workers and clinical psychologists. They support people with “complex/high risk presentations that cannot be managed in primary care.” Primary being the GP surgery, and secondary care the CMHT. I feel the need for a flowchart coming on!

Care and Treatment planning is a key element of the team’s work as a requirement of the Mental Health (Wales) Measure, the legislation which governs provision of mental health services. “This gives you the opportunity to set goals in all areas of your life, create a plan and, in the process, to take more control of your own recovery.” Hafal, A step by step guide.

There followed a brief discussion about the value of Advance Statements for Crisis Planning, a subject covered in a separate post. So far the day was proving very interesting.

Look out for Part 2 of this post next week to find out more about the roles of the Approved Mental Health Practitioner, the Crisis Resolution Home Treatment Teams, staff at Felindre Ward of Bronllys Hospital, and the Emergency Duty Team of Powys County Council Social Services in relation to Section 136 detentions. And, not forgetting, Jan Rogers' powerful personal story of coming into contact with the police during a mental health crisis.

Update: read Part 2 here.

What if "Restraint" was not an option?

by Freda Lacey

About this time last year the Minister of State for Care and Support, Norman Lamb, wrote about “Positive and safe: reducing the need for restrictive interventions” within health care. Mind’s report from the year before on “physical restraint in crisis” clearly outlined that the use of restraint was used to varying degrees and “face down” (or “prone” restraint as it’s sometimes called) was still being used despite the knowledge that it can cause serious harm and, in some situations, death.  The report made recommendations to the Government that the use of “face down” restraint should never be used in care and treatment settings.

The Mental Health Act Code of Practice, (currently being revised in Wales) devotes an entire chapter to “Managing behaviours that challenge,” and it clearly states that the least restrictive option(s) must be explored and restraint used only as a last resort.

The use of “restraint” and the “how”, when managing patients in hospitals, has been the topic of numerous blogs, reports, white papers, and news articles, particularly over the last few years. The Winterbourne Review spurred a great deal of investigation into the use of restraint, the Care Quality Commission specifically reporting on “Monitoring the Mental Health Act” in 2012/2013” and the use of restraint in hospitals. One of my favourite blogs is written by Mental Health Cop and he has his own views about restraint which may add texture to the topic. I am not going to write about how, when and where restraint is used in mental health settings, this has already been done by people far more knowledgeable than myself.

What I really want to highlight is how I’ve been affected by the topic of “restraint”. During my attendance at the Department of Health’s revision of the “English Mental Health Code of Practice” Expert Reference Group with Jan Rogers, I was privileged to sit in on several of the group meetings discussing changes to “the code”. The chapter called “Safe and therapeutic responses to disturbed behaviour” in the new Code of Practice made the experiences of restraint very real to me.

It was the first time where I listened to people’s direct experiences of being “restrained” in high, medium and acute wards whilst experiencing care under the Mental Health Act. I listened to family members speak of their experiences of witnessing their children’s restraint and the distress this has caused. People openly shared feelings of humiliation, trauma (some of this due to physical injuries they had sustained) and feelings of distrust in the people caring for them. They made direct links to the “way” they were physically restrained, sometimes stating they didn’t know “why” it had happened. I imagined how children or young adults may feel experiencing restraint and the trauma this may hold for them, particularly if abuse has been experienced. What is felt by people with a dementia, what comes up for them as a result of being restrained? As I listened, I wondered what would have happened had restraint never been an option. 

Interestingly around the same time, I caught sight of a national workshop on the management of violence in hospital settings. The workshop was pulled together by the “All Wales Senior Nurse Advisory Group for Mental Health” and their call to action really struck me. “The management of violence and aggression in mental health settings is a key issue for practitioners and educators. The Department of Health have recently consulted on restrictive practices in England along with the Mind publication in 2013; and we want to be at the forefront of planning developments and actions in Wales on behalf of our service users and our staff”. 

Having heard the recent stories from people who had experienced being restrained, I was curious to see and hear how staff approached the subject of restraint. The workshop was well attended by national ward management teams, general nursing staff, senior nurses and senior management.

 

One of the things that became apparent was that a good many staff felt the need to move away from restraining people and advocated “de-escalation” techniques, or “conflict resolution”. Basically, talking people down from a heightened sense of anger. I could see the difficulty experienced by staff when faced with a patient who is throwing punches and hurting them (one nurse spoke of being punched and having to be off work for some time) where the instinct is to restrain the patient so as to prevent being hurt. If restraint had to be used, then the workshop advocated using “supine” restraint or “face up” which is deemed less injurious and safer for the patient.

I volunteered to experience what it felt like to be restrained as in the afternoon we had a demonstration of using various methods of restraint for adults and older adults with dementia, (for example). Whilst the demonstrators were very careful with me (I was held down by two men and one woman), and pinned down so I couldn’t move and injure myself (and/or them), I was not trying very hard to be aggressive. I could imagine that if someone was very angry and aggressive that it may take some time of being held down and spoken with before the situation may diffuse. I was also startled at how quickly I went from standing to down on the floor and wondered if I was really emotional, angry and distressed, what effect the entire process might have on me. Also, if I were to be restrained by male nurses, how might this feel as a woman and similarly for men.

Hospitals are required to have policies on how to “manage” aggressive behaviour and in reading some policies from different areas I was struck by the following list of some of the things that staff should look out for as factors that may provoke disturbed or violent behaviour:       

• boredom and lack of environmental stimulation;
• lack of access to external space;
• personal frustrations associated with being in a restricted environment;
• difficulties in communication;
• emotional distress, e.g. following bereavement;
• antagonism, aggression or provocation on the part of others;
• physical illness;
• and an unsuitable mix of patients. 

It is worth noting that most of the above factors have been encountered by patients we see as part of the Powys Patients’ Council meetings and come up in patients’ feedback to us, so I wonder if these factors will always exist, to some degree, within in-patient units. If they do, then perhaps it’s not a matter of “may” provoke aggression, but that these are constantly having to be managed by staff in ways other than restraining patients.

One staff nurse mentioned that he worked within a high secure unit and that the staff never used restraint, that “conflict resolution” techniques were consistently used successfully. Here in Powys, ward management have mentioned that they don’t use restraint although staff are trained in Safe Physical Intervention Techniques or SPIT as it’s called. In fact, one of the staff on the ward here in Powys is the trainer for all Aneurin Bevan staff (including Gwent) in SPIT.

Another option for all psychiatric patients is to complete what is known as an “advance directive”, or here in Wales: “wishes known in advance” statement (we will be exploring this in more detail in a future blog post). This allows patients to state how they would like to be treated (or not treated) if they are detained by the Mental Health Act. They could quite clearly say that they don’t wish to be physically restrained and whilst an advance directive is not a legally binding document it would be good practice for hospital staff to respect the person’s wishes.

So, what’s the answer to restrain or not to restrain? It may be that while the Mental Health Act (and requisite Code of Practice) results in feelings of deprived liberty by people, there will always exist factors which may provoke people to behave aggressively. If this is the case, then ongoing debate and engagement on this topic will continue to be needed.

Finally, I’m curious to see if people may read something further into the paper outlined from the Department of Health mentioned at the very beginning of this blog post. It states, “This guidance forms a key part of the wider new Positive and Safe programme, which aims to end the unnecessary use of restrictive interventions across all health and adult social care." I wonder….

Dyfed-Powys Police - mental health: a multi-agency approach

Over the last few months I seem to have read endless articles online (the latest just last week from the BBC here) about the increasing numbers of young people and adults being detained in police cells whilst experiencing mental distress. This is often because there are no suitable places of safety where people can be taken to be assessed, even though it is frequently accepted that a police custody suite is not usually an appropriate place in such circumstances.

In Powys, a multi-agency approach is now working to improve the police response to those with mental health needs. I first found out about this in November 2013 at a Dyfed Powys Police event called Mental Health: the Way Forward. Here we heard, amongst other things, some of the Force’s plans for change in the area of detention under Section 136 of the Mental Health Act.

Inspector Brian Jones

This week we found out more, from Inspector Brian Jones of Neighbourhood Development for Dyfed-Powys Police, about how plans had been progressing since the event. Brian started by addressing the issue of children and adults being placed in police cells due to the lack of mental health beds.

“In Powys, we have not found ourselves in this position during 2014”. The police are often called to assist with situations where someone has expressed concern for a family member, a friend or someone they have seen behaving in a manner which raises concern for their welfare. The police currently have minimal training on how best to deal with incidents where people have mental health needs, but will strive to treat everyone with dignity and respect. “Our first priority is to ensure that persons are safe and then to ensure that persons are cared for by specially trained experts at an agreed place of safety.”

Legislation

The legislation under the Mental Health Act, which is known as a Section 136, stipulates that “if a constable finds a person who appears to him/her to be suffering from mental disorder and to be in immediate need of care or control, in a place to which the public have access, the constable may, if he/she thinks it necessary, in the interest of that person or for the protection of other persons, remove that person to a place of safety.” No one will disagree that a police cell is not a suitable place or environment for someone with mental health needs. However, there are occasions when there is no other suitable alternative and this is when there are signs of violence, substance misuse or criminal offences for investigation with evidence to be preserved.

In order to make every effort to secure the correct and professional support for individuals, as well as avoiding police cells or any inappropriate use of police powers, a procedural pilot was introduced in Powys in March 2014. This pilot requires the Police’s Inspector’s authority before police mental health powers can be used. The Inspector will take an independent overview of the circumstances which have led to consideration being given to utilising the powers under the Mental Health Act.

Exceeding expectation

The pilot is exceeding expectation and the police cells have only been used on three occasions, which was justifiable in the circumstances and not due to having no suitable beds available. At no time have the police powers been inappropriately used and at no time during this period have any youths under the age of 18 been detained. There is a strong partnership approach between the police and health and social care partners, who are working together to raise awareness amongst colleagues, as it has been agreed that training is required for people who come into contact with people suffering from psychological problems.

Thank you to Inspector Brian Jones for his update. Let us know in the comments box below what you think about the new ways of working that the police are trialling in Powys - or elsewhere in the UK.

You can read a recently published report (6 February) from the House of Commons Home Affairs Committee on Policing & Mental Health here.

Mental Health Act 1983 – Code of Practice: the review (in England)

Jan Rogers, who recently wrote for us about Volunteering whilst getting benefits, has been playing a key role over the last few months in the review of the Mental Health Act 1983 Code of Practice in England. This work is being led by the Department of Health and backed by the Minister for Health, Norman Lamb, you can read more about PAVO’s role in this work here. 

Jan was recently asked to speak about her experiences, as someone in contact with mental health services, at the Expert Reference Group reviewing the Code. With her permission we are publishing Jan’s talk as a guest blog post.

Hello, my name is Jan Rogers, I live in a small village not far from Newtown, Powys, Mid Wales. I am married and have been for nearly 36 years. I have 10 children although I did cheat a bit as my husband, Mike, had 4 children when I met and married him. Pre-1988 I lead a happy healthy “NORMAL” life. I used to do a lot of running, competitive and for fun, and also competed in a lot of different sports.

In 1988 a life changing traumatic event happened. Without going into detail, for a few years I pretended it never happened and it seemed to work but in 1992 “hell opened its trap door” and I fell in the most darkest place I had ever been.

I was diagnosed and labelled with "Post Traumatic Stress Syndrome” and depression. The reality of it all and the issues I have had to deal with, and still do, day to day – are guilt, lack of self worth, failure to family and friends and society in general (although after I was labelled I didn’t seem to have as many friends), flashbacks, voices, hallucinations (even to the extent I can’t always tell if the people I am talking to are real or not).

When I an unwell I tend to pace backwards and forwards with my fist clenched usually talking to the people that others may not see. I feel that this is the only way to keep control and to stop them taking over. In the past people, police, doctors and other professionals, have perceived me as on drugs or alcohol and mistaken my pacing and keeping control as lack of control and a possibility of turning violent. Those that know me know I am not, and never have been, violent towards anybody.

This Code will better safeguard people, carers and others that could be effected by the Code’s use. With every meeting I felt more confident in myself, maybe even talked too much sometimes, and felt confident enough to reply to emails if I wished. To be honest I’m not sure if I have had any conversations with people that possibly weren't there and still don’t. But I have never felt or been made to feel uncomfortable about the issues I deal with or pitied, only ever thanked for being honest. It has been great to be accepted for who I am. I spoke earlier about feeling like a failure to society but it’s projects like this that water this feeling down. I would like to give my personal thanks to the support I have received from Freda (Lacey), Derek (Turner) and Jane (Powell) in making it possible for me to come and take part.

Can I just say before I bore everyone too much that I really appreciate being involved in this work and even though we are playing a small part in a bigger picture I feel things are moving forward for the better. As much as our lived experience view helps professionals I also feel it’s helping me on my journey to living instead of existing.

Inspector Brian Jones of Dyfed-Powys Police asked if I would go along to a meeting and talk about how I was treated by the police when I had been arrested whilst being unwell. From here I have been involved in a lot of different projects. I have not been in hospital for two years and four months and I believe a lot of this is down to my volunteering and being involved with different projects like this.

Passing on my lived experience gives me a purpose and an outlet for the HELL I live in sometimes, along with the support I have had from the staff at Ponthafren, PAVO and the Community Mental Health Team, and last but certainly not least, my “Mountain” (my hubby and family).

When Freda asked if I would like to put my name forward with a possibility of being a part of “The Expert Reference Group”, I said yes, and when she came back a short time later and explained that I had been accepted I was excited. Then panic set in. I started thinking what if I upset people by talking to people that nobody else could see? What if I couldn’t make out who was real and who wasn’t? I have in the past while doing a card making workshop spent 10 minutes showing an empty chair how to make decoupage cards and it wasn’t till I noticed the others looking rather confused that it dawned on me. Thinking quickly I said I was practicing, now I will move on to a real person, phew, my mum always said I was born in a knife drawer.

Another thing that was going through my mind….. As I said, I have been involved and gone along to quite a few different meetings and projects, but sadly there have been a few where they said they wanted input from people who use the services but I soon realised that actually it was more that they needed to tick a box to say that they had input from us. And I really felt as if I was invisible.

Between 1992 and now I have been arrested under the Mental Health Act and held on a Section 136 over 30 times. Every time I have ended up on a section and taken to hospital. I have been pepper sprayed, thrown in the back of a police van in a cage, held down in handcuffs over a wall, while the police officers spoke to their sergeant over the radio as to where they could take me (as the police have always thought that a cell is not the best place for people suffering mental health issues), stripped of my clothes in a police cell, bearing in mind to me the cell had between 15 and 25 people in it at any one time….

All this I believe was because of a lack of training and being unsure of what exactly to do with people struggling with mental health issues. Sometimes even a lack of understanding. It would have been interesting if any of the officers involved took any advice from the Mental Health Code of Practice! On the other hand when it has been officers that have known me, things were very different. They allowed me to pace instead of being forced and held down, spoke quietly and at a distance and even allowed me to have a fag.

After years of being in and out of hospital, cutting a long story short, I came into contact with Ponthafren Association, which is a resource centre for people with mental health issues or those that feel lonely or isolated. Through doing volunteering there and becoming part of the public relations group, I met Freda Lacey a lady that works for PAVO, (Powys Agency for Voluntary Organisations). Through Freda and PAVO I met Inspector Brian Jones from Dyfed-Powys Police force who chairs the Confidence and Equality Group meetings in Llandrindod Wells every quarter. There are representatives from several front line organisations.

Also maybe in some people’s eyes a serious problem, I listen constantly in one ear to 60s music as I found it’s the only way I can listen to a conversation with a real person as it quietens the voices a bit and helps me concentrate.

I remember the first time I came down to the Expert Reference Group, my stomach churning and brain spinning and the voices and extra people were worse than they had been for a while. When we all introduced ourselves and I explained the issues I deal with, voices etc, straight away I felt accepted for who I am - lock stock and barrel - and this meant so much to me it’s unexplainable in words really.

Well! From the time I got there it has been an extraordinary journey, from everyone’s attitude, explaining what it is all about, directions, travel and follow-on emails about the previous meetings, and future agendas. The meetings and discussions felt like they flowed, we all were able to give and were asked for our views. When the Minister and other professionals came along to some of the meetings, I felt it went well as we were all able to have a wider view of things. It felt so easy to put my point of view across and I personally felt very much listened to. To be able to play a small part in reviewing the Mental Health Code of Practice for England is unbelievable and a great personal journey and already leading to other things.

I feel I have learnt so much as when I first looked at the Code I was totally pickled but now I feel that, albeit a small step, the Code will be much easier for people who use the services, carers, and professionals to use and understand, as I’m sure a lot of the areas which were very grey and doubled up will be more understandable.

Many thanks to Jan for sharing her experiences of the review process with us. You might also be interested to read a blog post by Aimee Wilson about her experience of reviewing the Code of Practice. She was initially approached by a Youth Engagement Worker from Young Minds and asked to get involved.