Triage and Assessment Policy | Atrium Prison Counselling Service.

Forensic Document Information

1. Introduction

This paper sets out the principles and role of assessment and triage services in Atrium forensic counselling pathways.

Working to time scales – HMP Wormwood Scrubs and Thameside, Isis and Belmarsh

There are clear contracted time frames for triage, assessment, and sessions delivery.

It is a contract requirement for a member of the Atrium team to attend the Multi-Disciplinary Referrals Meeting if staff are on site on the day. At HMP Wormwood Scrubs the MDR meeting is currently held on a Monday, Tuesday, and Thursday (12 -13pm). At HMP Thameside the MDR meeting is held on a Wednesday morning (9am – 10.30am). At Belmarsh the MDR is held on Tuesday at (12 to 1.30pm) and in Isis the MDR is held on Tuesday at (2pm to 3pm). The person attending the MDR meeting would usually be the Prison Lead (who also processes and allocates referrals) but in their absence practitioners on site will be asked to attend the meeting on their behalf.

The referrals allocated to Atrium during the MDR meeting are tasked to the Atrium System 1 Inbox. This Inbox is cleared once weekly by the Prison Lead who then allocates the referrals to the practitioners.

There are two types of referrals:

• Priority Referrals – to be seen/assessed within 5 working days
• Routine Referrals – to be seen/assessed within 28 working days

Wait management process:

Usually “seen/assessed” refers to completing a full assessment (and this would be considered best practice) but in the event of delays (such as has been the case during the current COVID-19 pandemic) practitioners are expected to at least complete a SASH/Welfare check on their allocated clients within this time frame.

SASH and Welfare checks:

SASH Clients will be seen as soon as the referral is accepted onto the Atrium caseload. They will then receive a SASH check every week whilst they are waiting to be formally assessed and/or before commencing counselling.

Welfare checks are only provided to routine referral clients during periods (such as the COVID-19 pandemic) when Atrium therapists are unable to provide formal assessments and counselling sessions due to restrictions to working with clients. During these times routine referral clients will receive checks fortnightly or weekly depending on the number of clients on our caseload and waiting lists.

There is a difference between a SASH check and a Welfare check (although some cases might overlap):

• The SASH (Suicide and Self-harm) protocol (see full SASH protocol document, Appendix to this document) was introduced to manage the risk of harm to clients presenting with risk of suicide and self-harm on the Atrium waiting list. SASH clients need to be checked in weekly by the allocated practitioner.

Clients would be put on the SASH protocol if they:

• Have been referred for suicidal ideation or self-harm
• Are on an ACCT
• Present with risk to themselves (at time of referral, first contact, or at any stage in their journey with Atrium)

Please note that most priory referrals can be considered as SASH clients until assessed otherwise.

Clients can be taken off the SASH protocol:

• Once they have been assessed as safe to do so (e.g., risk factors have been removed/managed, client stopped experiencing thoughts of self-harm and suicidal ideation over a long enough period of time, circumstances have changed, etc.…)

It is crucial to clearly document the reasons/ rational for putting a client on or taking a client off the SASH protocol on the System on notes.

2. Welfare checks

Welfare checks are completed on non-priority referrals/clients when Atrium therapists are unable to provide formal assessments, or counselling sessions due to restrictions in the prison:

• within 28 working days of allocation if not able to assess client (see above)

Please note that it is crucial to assess risk alongside client’s wellbeing each time you touch base with a client – if risk changes, please change client status to priority or place on SASH protocol where appropriate.

Notes:

System one notes are expected to be recorded as soon as possible and must be recorded on the same day of the interaction with clients. The case log needs to be updated at the end of each working day.

CORE notes are expected to be updated within 24hrs of client contact.

Priority clients should wait no longer than 2 weeks between their assessment and first counselling session, and routine clients should wait no longer than 4 weeks between their assessment and first counselling session.

3. The Assessment Purpose

Atrium is a primary care level provider of psychological and therapy interventions alongside prison mental health services and psychological interventions. Assessment should always be for a purpose. In a bigger inter- connected network of mental health services, there are a range of contributions to a collective understanding of the client’s needs that the single assessment addresses. A good forensic service triage and assessment

• Identifies people who are at risk for more rapid triage, ensuring clinical notes are clear, timely and record risk.
• Collects information with the client about the client that also feeds into the collective understanding of the client’s needs. EG Prison data collection, mental health service information
• Balances the needs for specific data collection for the system with a more complex understanding of the client’s needs and how they might be met.

4. Assessment Approach

• Is a co-production so the client can gain insight about himself, his challenges and goals and his context, person centred (but structured and boundaries to keep client safer), non-judgmental, warm, and empathic.
• Meets the requirements of the client –access/cognitive/ behavioural style etc.
• Trauma informed- encourages client empowerment, self management and as much control in the space as the context allows.
• Provides an opportunity to develop trust with the practitioner and have a realistic expectation of next steps and how the system connects to deliver coordinated services.
• Prepares the context for therapeutic work- ensures that the limits of confidentiality are shared and understood and considers the client’s relationship with help; what will support him in counselling and what will be a barrier and the common features of the work.
• Considers how the work can fit into the future and that every client is discharged with a plan for continued improvement.

5. Assessment

5.1 History and Formulation

• History – Childhood, health, accidents and conditions, traumatic events, family life, school, and access to education, checking in on features of neurodiversity and further follow up questions as required. Social networks, support-history, coming up to current day.
• Risk and Safety
• Every client should have a safety plan routinely and this should be recorded. Risks should be recorded, and risk management protocols initiated and recorded as soon as possible. The pattern of self-harm/when and where Safeguarding and risk management.
• Current situation – engagement with other services (on the inside and outside, medication, mental health issues/ diagnosis if applicable).
• Presenting issue – needs for therapy

5.2 Problem formulation assessment session

• Ask the client what their biggest problems are or reasons to want counselling?
• Come to an initial shared understanding Formulation of the client’s problems, where the client feels they have communicated their problems and been understood. Could another professional see these notes and understand the formulation and recognize that the plan of work is appropriate? Is there enough detail but not too much so another person could pick up the work?
• The Assessment outcome is a shared understanding of the problem, protective factors and strengths in person’s life and an outline plan for the work together.
• A broader systemic frame on the problems, a relational understanding of when and with whom problems are worse or better can be useful; drilling down into situations that inform patterns of emotional responding and behaviours is helpful.
• Explain the risk assessment framework running through the Atrium counselling process (CORE 34/10) to ensure that the client’s needs are being met and to review the wellbeing of the client and how this will be a regular feature.
• The formulation of the client’s needs should be ongoing through the counselling and changes reflected in the clinical notes.
• Where possible in the assessment session, the client and practitioner should focus on some goal areas for the work together. These should be SMART, when possible and particularly achievable within the time scale of the work.
• Assessments are updates and re-formulate alongside risk assessment at the beginning of sessions and in notes

6. Recording of Assessments and Notes

6.1 Example of assessment and tentative formulation:

Background:

John is a 30 y/old male of mixed ethnicity. This is his first time in prison, and he struggles with the prison environment and being away from his family (girlfriend and 5-year-old son). He also struggles with the uncertainty regarding his court case and does not believe he should be in prison. Client reports no history of mental health issues but is currently on Mirtazapine to help with low mood and poor sleep. Client was referred for poor coping.

Client grew up with his mother (saw his father only occasionally) but spend most of his time with his grandmother who he considers his main attachment figure (she passed away 10 years ago). Reports difficult family relationships and difficulty regulation anger. Client has reports struggling with low mood and anxiety since his teenage years and reports mostly coping with these feelings by keeping himself busy or drinking alcohol. He currently lives with his girlfriend and his 5-year-old son but reports the relationship with his girlfriend has been difficult since coming to prison. He reports occasional thoughts of self-harm and suicidal ideation (states they were worse when he arrived to prison) but denies any plans to act on them.

Initial thoughts/summary/observations:

Client presents with low mood, anxiety and anger which seem to have increased since coming to prison. He experiences occasional thoughts of self-harm and suicidal ideation (no plans to act on them) that have decreased over the last few weeks as he is getting used to the prison environment. Client reports experiencing low mood, anxiety and difficulty regulating anger on the outside, but he feels less able to cope since being in the prison, not being able to see his son and resorting to his old coping mechanisms.

Formulation

Client struggles with current situation of being in prison and away from his family especially his 5-year-old son. Client appears to lack tools and support to manage/regulate his current feelings. Spending time in his cell has also brought back a lot of feelings (especially resentment) from the past.

Treatment Plan/Planned therapeutic journey (agreed with client):

• Offer client a safe and validation space to talk about/express his current feelings
• Help client reflect on impact of past on current issues and understand himself betters
• Help client navigate relationships better
• Help client find strategies to better manage his emotions better (offer psycho-ed where appropriate)
• Help client develop a support network (inside and outside the prison) – discuss support options available in the prison e.g., groups, education, work.
• Continuously assess risk as work progresses

6.2 Find below an example of how this would be recorded in notes in System 1:

#XXX Atrium Prison Counselling Service: Client seen for initial assessment. Client engaged well throughout and would like support to better cope with his current situation. Client reports experiencing occasional thoughts of self-harm and suicidal ideation but denies any plans to act on them at present. Agreed to talk to member of staff if this was to change. Pending priority 1:1 and client to remain on Atrium SASH protocol to continue to monitor risk.