Life at the Coal Face by Nina Bradshaw

An insider’s account of working in modern mental health services

I worked in a Home Treatment team for almost 2 years. I took the job reluctantly, after deciding to give the NHS another chance. I had previously worked for the NHS in various roles for 12 years.

Most recently I worked for a team that provided support for people diagnosed with Personality Disorder (PD). The service ran a therapeutic community (TC) and the team was basically run along TC lines – with a flattened hierarchy; regular team support (weekly supervision); collaboratively working alongside the service users; and with a relatively high-risk threshold. This meant we tried to work with people and their distress, recognising that the way of expressing their distress might sometimes mean taking massive overdoses or putting themselves at risk in other ways, and trying to contain people and help them find ways to express their pain rather than act on it. But in a patient way. We tried not to coerce people into stopping their risk taking through such measures as, for instance, enforced treatment. It didn’t always go as planned – how could it? There was one time I was so worried about a service user that I thought a long-stay, properly funded, therapeutic in-patient stay would be preferable. But overall, team support was in place so that practitioners felt supported in what they were doing, not constantly under threat of punishment if a service user ‘went too far’.

This service also had two ‘add-ons’ – diagnosing and treating Adult ADHD and Autistic Spectrum Conditions (ASC). These were things the commissioners wanted, and they were in the National Institute of Clinical Excellent (NICE) guidelines. However, these elements were not seen to fit anywhere else, so were tacked-on to a specialist team for clients diagnosed with PD. Over the course of the service, the commissioners began to realise that adult ADHD and ASC services were lucrative and wanted to ‘sell’ them to other local NHS trusts. The PD part of the service was closed and me and my colleagues were asked to take on assessment and diagnosis of ASC (no treatment or support, just assessment and diagnosis) and some supportive work with the more troubled ADHD clients (the main ‘treatment’ for ADHD being stimulant medication, of course).

I left this job as I had taken the job originally because I had a particular interest in working with people diagnosed with Personality Disorder. I felt quite disillusioned with the NHS at this point, so returning 2 years later was a big step for me. I wanted to train in psychotherapy and needed a decent income to fund this. I had worked for the voluntary sector for a short while in the interim, but funding and wages in that sector is fairly grim.

In the Home Treatment team, the picture was very different from the TC job. We were inundated with patients presenting in crisis who were highly distressed and highly risky. Colleagues were terrified of ‘ending up in coroner’s court’ or losing their ‘PIN’ (these were daily comments). The service was supposed to have a maximum caseload of 60. Yet it wasn’t uncommon for there to be twice that number ‘on the boards’ (written up case-loads on whiteboards). When I arrived, I asked about supervision. It turned out most of my colleagues didn’t have any, whether case management or clinical. My colleagues were so burnt-out they thought this was acceptable. In fact, supervision was seen as a luxury. When I did find my own supervision, I had to sneak out of the office to take the time to discuss the distressed and distressing people I was working with.

We had no way of keeping our caseloads down. Senior management often coerced us into taking on more clients. The result was a team rife with splits, paranoia and we felt totally un-contained. The anger was taken out on each other with in-fighting, and on the clients with excessive use of labelling, over reliance on medication, and the over-anxious use of coercive measures. One client I went to see told me that a colleague had said to her ‘Don’t kill yourself or I’ll lose my pin’ [1]. The police were used regularly to ‘chase’ people who had not been seen for a few days. For instance, if someone rang in distress saying they felt like killing themselves, the most common response was not to talk to them – to find out why they were feeling like that – but to call the police to get them to check up on them. This was a complete waste of resources and further alienated clients who were already in a lot of distress.

The whole atmosphere of the place was high-octane anxiety and paranoia. There was no time or space for thinking. When I tried to flag these issues up with my manager, I was seen as a trouble maker, or ‘too sensitive’. NHS machismo was winning the day. It impacted on me to such an extent that I felt suicidal at times. I was also working through my own stuff in therapy, having had a history of depression, and it is a requirement of my psychotherapy  training, but the distress I was carrying as a result of working in the team massively amplified my own stuff. Another colleague did attempt to end their life. Again, this was due to a mix of personal issues and work stress, but no support was put in place for colleagues even after major incidents like this. When a patient ended their life, the team became even more defensive and risk averse, convinced that punishment was imminent.

The final straw was when the team was forced to undergo major changes, to come in-line with standards from another NHS trust that had taken over running the service. These changes had far-reaching implications. There had been a ‘consultation’ exercise for a few months but myself and most of my colleagues did not feel we had time to attend, as we were so snowed-under with the day-to-day work. Besides, the consultation was really only lip-service as the changes were pushed through anyway. In the space of a month, almost everything about how the team operated changed. The process was managed so poorly. In fact, I would say it wasn’t really ‘managed’ at all.

One of the major changes in staff contacts meant going from working days and evenings to working nights. If I had wanted to ‘opt-out’ of this contractual breach (on behalf of the trust), I would have had to go through Occupational Health to mark myself out as ‘ill’ – the implication being that if you can’t cope with such massive changes, there must be something wrong with you. In addition, the ‘qualified’ team members would now be mainly carrying out assessment work – to gate-keep the service, or access to a hospital bed – rationing in other words. The minimal case-work with clients was relegated to a sideline, or largely carried out by support staff. It was not much of a service at all really. So I left, even though I didn’t have another job to go to. I felt there must be a better way to do this.

Writing this now, I had not realised how caught up I was in the overwhelming sense of despair and hopelessness. It felt like it must be something I was doing (or not doing) that caused me to find the work so difficult. I also feel extremely angry. The patients were treated like shit, and the staff equally so. I am a skilled and experienced mental health worker, and I left feeling inadequate, ill-used and that there must be something wrong with me. Writing this has been cathartic, to some extent, as I am able to see how mentally warped this service was, and sadly still is.

It makes me so angry, sad and frustrated that so-called mental health services can disregard the needs of its workers so massively. What does this say about the way the service users are thought of or treated?


1. A PIN is a nursing registration number. The threat was that staff could be de-registered from the Nursing the Midwifery Council (NMC) and thus ‘lose their PIN’. It was a very medical team. Social workers don’t have PIN numbers, but there were far more nurses in the team.


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