Whilst working for the NHS in a primary care mental health service, I remember walking into the community mental health team’s monthly referrals meeting. The meeting was to discuss the referrals made to the service, and to which clinician they are allocated. Towards the end of the meeting the less intense cases were allocated to the more junior clinicians (like me at the time). At this point the consultant psychiatrist insisted I assess Frank (not his real name) for his suitability for cognitive behavioural therapy to treat his depressive symptoms.
Frank had recently been made redundant from his job. The mental health service I worked in provided cognitive behavioural therapy to people suffering from mild to moderate symptoms of depression and anxiety. Cognitive behavioural therapy aims to get people to understand how thoughts, feelings, physical symptoms, and behaviour are all linked. Negative patterns of thought about the self and the world around them are challenged and re-structured to alter unwanted behaviour patterns.
A man in decline
Whilst reading Frank’s file I could see that he was also under the supervision of the probation service. Upon being made redundant, he had committed a common assault on his boss on the last day of work at the local processing facility where he was employed. The assault involved slapping and making threats to him on the way out of the facility. Frank was angry about being made redundant. He was in his mid-fifties and, like 40 other employees, had been made surplus to requirements due to his job being automated. He received 18 months on a supervision order for common assault. Later, his GP referred him to the community mental health team after Frank had presented twice at the surgery feeling depressed.
Thinking interventions through carefully
The probation officer soon understood that Frank was worried about his job prospects. Both his age and skill set were no longer suited to his newly automated industry. These two facts were potentially disenfranchising for him. Frank’s probation officer was supportive of the GP’s referral to mental health services. Whilst in conversation with Frank’s probation officer, I learned that the first three probation appointments did not go to plan. Non-attendance, poor punctuality and a disagreement, which ended in a verbal argument, could have potentially landed Frank back in court. Luckily for him, his probation officer had recalled his own experience of being made redundant whilst working as an engineer, and could take a considered view of Frank’s situation. Another phone call from Frank’s probation officer a week later resulted in us both agreeing with each other on the fundamental point: a criminal justice intervention alone was not the best way to serve him or reduce his risk to the public.
Treating his symptoms of depression were of obvious benefit to Frank, as he was willing to engage, however, mental health treatment alone was not going to help him. His ambition was to get back to work in the field he had been made redundant from. That would require Frank to upskill, and re-train, and become computer literate. He was unable to use the internet, and had managed reasonably well, though this was unsustainable for him. We agreed breaching him for his poor start to probation service supervision was not the answer. Referrals to mental health treatment and local training providers were the pro-active way to improve things for Frank and public protection.
When I met Frank to conduct his assessment, he made it clear to me what the problem was. He was depressed at the fact that his identity had been stripped from him. His identity had centred around his working life and the social circle connected with it. The idea of being unemployed was new to Frank as he had worked uninterrupted since leaving school. He now felt vulnerable and revealed he had a history of depressive episodes after experiencing a divorce. I could see that Frank was an intelligent and open man. He was also a pragmatist who understood the benefits of the support he was getting from me, but knew it was not enough to help him ‘get back on his feet’. Frank knew he had to get to grips with learning about computers. He knew that he had been made surplus to requirements not because of anything he had done wrong, but because his skill set required updating.
A year on from completing treatment, Frank was having twice yearly reviews with his GP to monitor his mental health. The pro-active approach of his probation officer helping Frank to upskill meant he was six months into a 10-month paid back-to-work training scheme with an engineering firm. An opportunity that Frank had found on the internet at his local library after completing a basic internet literacy course. The scheme was paying Frank a salary as well as providing him with training in automated processing systems.
A clearer, more secure way ahead for Frank and the public
A man of Frank’s experience was a benefit to all around him on the course, and he eventually found a more secure job elsewhere. Completing a brief course of cognitive therapy and acquiring employment is not a guarantee that Frank will never be depressed again or commit a crime. These two things are good, protective factors that reduce the likelihood of him relapsing into unhelpful thinking and behaviour again. Frank’s case led me to ask the head administrator in the community mental health service about how many cases like Frank we had received recently. It turned out that 15 per cent of referrals to our mental health service that year were people who had lost or reduced employment prospects due to automation. Probably not since the industrial revolution during the eighteeth century have we seen an upheaval of this kind. As automation continues to gather pace, the criminal justice system and the mental health services need to be mindful of its side effects, as they may be the services that bear the brunt of any upheaval.
Gavin Wilkinson is a Forensic Mental Health Practitioner at Together for Mental Well-being’s Forensic Mental Health Service