In the twenty years that I have been a clinical supervisor, delivering both individual and group supervision, one of the most consistent issues brought for discussion, or emerging from the reflective discussions, is that of clinicians’ difficulty in discharging individuals from mental health services. This is generally a community issue when, either a single clinician is the only practitioner working with a service user, or they are the care coordinator and the last clinician still working with an individual after other members of the multi disciplinary team have discharged the person from their own caseloads. A recent literature search found many papers that discuss the discharge process from hospital for those with mental health problems, but nothing examining discharge from caseloads, or from services in the community.
Just in case
One of the most cited reasons in supervision for not discharging from service is the ‘just in case’ position. Here, the service user is often doing well and has little need for input from services, but the clinician still holds them on their caseload ‘just in case’ there is a change. Whilst this is done with the best of intentions, it is the antithesis of recovery. By not discharging when appropriate, an implicit message can be given that the service user is frail and needs support. The progress that a service user has made, and how hard they have worked, can be devalued with a sense that, ‘whatever you do it will never be good enough’. Not discharging a service user loses the momentum of hope, of which workers should be the bastion. The chronic retention of individuals on clinical caseloads, signals to service users that they are always going to need services and that they will never be able to manage totally on their own. Whilst this might be done with the impression of being service user focused, it hints at clinicians’ needs being put first – to manage their concerns about what might happen if they discharge someone.
Dependence, the new institutionalisation?
Thirty years ago many of the old psychiatric asylums were still standing and in use and institutionalisation was viewed as a secondary diagnosis, one that was caused by the very services that provided care for those with mental health problems. Whilst institutionalisation is now less of an issue, dependence upon services, and also on others who provide support, is well recognised. Dependence upon services is often viewed as something that service users, especially those with particular diagnoses, have deliberately created. Frequently there is a lack of consideration about how workers and teams may have had a significant role in creating the situation. When discharged from mental health services, many service users need an appropriate, rapid and easy route back to care. Often these routes do not exist, or are difficult to navigate, and service users and carers are understandably anxious about being able to access help should it be required in the future.
New ways of working
Holding on to service users is often described by workers as wanting to keep the things the same as they always have been because the ‘old’ ways of working with individuals in the community were the best and these provided the optimum support for service users. Whilst this might have been the case to a certain degree, it is possible that workers use this way of keeping long term consistent caseloads as a method of managing and controlling their own anxiety about the changes in practice that are being asked of services and those who work in them.
Many clinicians and service users are nervous or sceptical about care clustering in mental health but one positive aspect of care clusters might be that they will outline care pathways for people to move through mental health services, receiving the care they need and with reviews at appropriate points. Care clusters give criteria that indicate when discharge should be explored and a return to primary mental health services considered (DoH, Mental Health Care Clustering Booklet). If clear and responsive access routes back to services are made available, if needed, this could really support recovery for individuals. Care clustering may help all concerned to be clear about the processes during treatment delivery, discharge from services, re-referral and return, should these be needed. Care clustering could also enable clinicians to feel confident to discharge people from their caseloads.
How we feel about those we work with
Reflecting upon and discussing our feelings about those on our caseloads is difficult. Hawkins and Shohet’s (2006) Process Model of supervision supports supervisors to explore with their supervisees their feelings, thoughts about and interventions with those they work with. A useful question to ask a supervisee is, “Do you like the individual?” This is often difficult for workers to answer as they can believe they shouldn’t have human responses to those they work with, although feelings are inevitable when we work at deep levels with other human beings. When co-teaching a clinical supervisors course, with a social work colleague, we explore this tricky issue of asking supervisees how they feel about their service users. Our students very often recognise that they can hold on to service users longer than they might because they like the individual. This positive feeling results in workers wanting to protect the service user, and we come back to the ‘just in case’ position. More concerning is that clinicians might be holding on to service users as they enjoy working with them as they give clinicians a feeling of job satisfaction. This idea is not a new one as research, now old, by White and Brooker (1990) highlighted that a client group described as the ‘worried well’ were more likely, at the time, to be attractive to work with for Community Psychiatric Nurses as this group of service users provided more job satisfaction for professionals than did those with severe and enduring mental illness. When this happens clinicians are meeting their own needs, not those of the service user, and this does not align with a recovery approach.
My co training colleague has an interesting view on how clinicians feel about those they work with. He proposes that there is a risk that clinicians will retain on their caseloads service users that they don’t like or about whom they don’t feel positive. Clinicians can believe such feelings of dislike are inconsistent with their role and this dissonance may cause the clinician to retain the service user for longer than necessary and work harder with them to compensate for their feelings.
How we feel about our service users can be a ‘taboo’ subject. However these emotions are inevitable and normal when we build significant therapeutic relationships with others and use ourselves as the most important tool in our practice. We walk alongside service users as they have so many experiences, many of them extraordinary. We are honoured to be confided in, when service users tell us things that they may have never told anyone before and we are often the keepers of these confidences. Skilful, reflective clinical practice can support recovery, but when there is a lack of self awareness and openness by clinicians it can build unhealthy relationships, and caseloads, creating dependence and loosing the important principles of recovery.
Therefore, it could be suggested that holding on to our service users for too long is a natural temptation for all practitioners, for a variety of very human reasons. We should not be ashamed of our feelings about those we work with, rather we need to be open, reflective practitioners and confident to seek space to honestly and professionally explore these. Clinical supervision is one of the essential support mechanisms in which to do this. If we do not address these issues within ourselves we cannot be working in a recovery focused way and we, at the very least, do our service users a significant disservice.
Originally published in The Approach (Care Programme Approach Association)
With thanks to my co training colleague Keith Noble for some of the ideas explored within this article.
White E. & Brooker C. (1990) The care programme approach. Nursing Times. 87, 12, 66–67.
Hawkins,P. and Shohet, R. (2006) Supervision in the Helping Professions. 3rd edition. Berkshire: Open University Press.
Department of Health. Mental Health Care Clustering Booklet 2013/2014.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/216217/dh_132656.pdf (last accessed 27.8.13)