Success in the last chance saloon

A young Asian woman diagnosed with
schizophrenia was on the verge of losing her “last chance” place in a
residential unit. Then Marianne Thomas and her team stepped in at the 11th hour
to give her more autonomy – and keep her out of hospital, writes Graham Hopkins.

Nine months ago a young Asian
woman’s hopes of getting a flat or a job seemed a lifetime away. Kashmira
Narayan (not her real name), diagnosed with schizophrenia, was challenging her
health and social care services to the limit. Already sectioned a number of
times, there were serious doubtas that she could function healthily in the
community. A challenging behaviour unit was emerging as the final option.

On the verge of having her
last-chance residential care placement terminated, Narayan received a boost
following the creation of a new assertive outreach team. With promised
intensive support from the team, the residential home agreed to Narayan
staying.

“While an in-patient she was
aggressive and verbally abusive,” says outreach worker Marianne Thomas, who
began working closely with Narayan. “When we got to know her, a lot of the
outbursts in the ward seemed part of a negative cycle. She’d have leave, would
have an outburst, have leave stopped and so on.”

There was also concern about her
solvent misuse and that she took cannabis regularly. “This meant she felt that
she was being locked up as ‘a naughty girl’, and felt she was being punished,”
adds Jo Fuller, the assertive outreach team manager. It was explained to
Narayan that although she might think that cannabis-taking was part of a
24-year-old’s lifestyle, it has a negative effect on her condition.

“Because she felt she was in what
seemed to her like prison,” adds Thomas, “she was reacting to that. We saw our
role as focusing on her as a person.” It was a focus that began to change her
life. Although looking long-term, Thomas concentrated on getting Narayan
established away from hospital and into the residential unit.

“We knew it could all go wrong,”
says Fuller, “but there really was something engaging about her.” Thomas
agrees: “There were a lot of practical things we could help with. She was very
vulnerable. There was financial exploitation which was out of her control,
which if eliminated would reduce the risk for her.”

Thomas arranged for Narayan’s money
to be managed by social services. “She now gets an amount each day, which means
that she doesn’t have books that people can take and cash,” says Thomas.
Although this action could be construed as controlling, Narayan agreed to it
and is now relieved at the arrangement: “It helped her realise what was
happening. There was one person she was having a relationship with but who now
doesn’t want to see her because the money’s not there.”

The outreach team work 365 days a
year including weekday evenings, making themselves more available for Narayan.
“The big thing for her,” says Thomas, “was seeing her as a person. Rather than
focusing on ‘are you taking your medication?’ we’d go to the hairdressers or go
swimming.” Realising that she can work with the team rather than kick against
it, Narayan is responding well, particularly as she can see progress, albeit
slowly, being made. “She is attending an adult education class,” says Thomas,
“but still wants that normal life – that job, that flat. That’s some way off
but it seems a possibility now.”

Thomas, recognising Narayan’s
fractured relationships with family and boyfriends, focused on building trust.
The “everything up for negotiation” approach, belief in her possibilities for
advancement, advocating on her behalf with other services ready to give up on
her, and consistency in her life are delivering rewards. “She’s just asked if
she can have a mobile phone,” smiles Thomas, “so that when she’s out or stays
out she’s able to keep in touch. Also she feels confident enough to tell us
she’s feeling unwell or hearing voices again – I think she knows that if she
tells us things, we can work through it and stop her being sent back to hospital.
So I think that trust is really working.”

“For years,” adds Fuller, “she’s
either been in hospital and contained, or out and been completely chaotic. This
is the first time she’s been settled for years. And it can still all go wrong –
she has a history of things going wrong, after all. But for every month that
she’s out and managing and coping, that’s a positive thing – and all down to
positive risk taking.”

For Narayan, having her own flat and
a full-time job may still seem a lifetime away. But for now she’s living safely
in the community and Thomas is exploring the possibility of Narayan taking on
some voluntary work for a couple of hours a week. It may be some years before
there is light at the end of the tunnel – but at least they’re in that tunnel
and travelling the right way.

Case notes

Practitioner: Marianne Thomas

Field: Occupational therapist and
outreach worker, assertive outreach team, mental health

Location: London

Client: Kashmira Narayan (not her
real name) is a 24-year-old Asian woman who has been known to social services
for seven years and has a diagnosis of schizophrenia. She also has a history of
substance misuse, particularly solvents but other soft drugs also. She has been
sectioned on several occasions.

Case History: Four years ago,
following another spell under section in hospital, Narayan’s family took her
back to India to be married – hoping this would cure her illness. It made
matters worse. Within months she returned to England without her husband, now
estranged, because she was so unwell. She moved back in with her parents but
this soon became untenable. The house was overcrowded, added to which Narayan’s
father, who drank excessively, was verbally and physically abusive towards her.
A number of residential placements subsequently failed because Narayan was very
chaotic, difficult to engage and challenging, while her solvent misuse
escalated, endangering her health. She was also being exploited by a succession
of boyfriends.

Dilemma: Narayan, a bright and
articulate young woman, was proving very vulnerable to sexual and financial
exploitation.

Risk factor: Supporting Narayan to
become more independent may lead to more failure and see her sectioned again.

Outcome: Narayan is making slow but
sure progress in taking control of her life.

Arguments for risk

– The team were sure that with the
right support it would be possible for Narayan to live in the community.
Narayan deserved another chance to experience more independence and the
improvement in the quality of life that goes with that.

– For the first time in years,
Narayan was achieving some stability and building trust in her life and the
time was right to make progress on that.

– Although Narayan argued cogently
against nurse-injected medication to convince the team that she should use
replacement oral medication, she has shown maturity by understanding that she
needs some sort of medication and that if the new system fails to work she will
resume with the injections.

– Narayan’s residential home has
worked well with the team despite ambivalence from some care staff about giving
Narayan one more chance. This has provided a permanent base for her – adding to
the consistency in her life.

Arguments
against risk

– Narayan’s recent history would
indicate the possibility of misusing drugs again.  The more she felt she was living a normal life, the more she
might be tempted to take drugs – something she considers part of a normal
lifestyle. The scale of her solvent misuse had caused worries about possible
brain damage, with cannabis also having a negative effect on her condition.

– As Narayan enjoys more
independence, there is the possibility that she may cut off contact and revert
to her old lifestyle. This may result in her being sectioned again.

– Given the team’s open and non-restrictive
approach to working with Narayan, she might consider that the team are
condoning her actions.

– At her last care plan approach
meeting it was agreed, although not without reservation, that rather than a
nurse administered system, she would receive replacement oral medication,
which, although managed by the staff in her care home, would give Narayan more
opportunity to avoid taking it.

Independent comment

The family’s arrangement to have
Narayan return to India is a typical response when an individual presents
delusional and bizarre behaviour, the belief being that local healers can erode
the spirits that are causing the behaviour, writes Raj Jhamat. It is also a
common response to have a woman married off without fully detailing her mental health
difficulty to her future husband and in-laws. This more than often leads to
young women being traumatised by abusive in-laws and subjected to domestic
violence.

The support Narayan requires appears
to have been identified in clinical terms but there is a missing element around
independence. Within Asian communities, connections to family and the community
are far stronger than those of the white population. Isolation can lead to
further mental health difficulties.

At Sahayak befriending service in
Kent, we offer support to people rebuilding lives outside of the family. We
also seek to build bridges back to the community.

Mental health promotion helps
families and community leaders understand the complexity of mental health
difficulties and to remove taboos. Gaining the community leaders’ support opens
up referral channels that would otherwise avoid existing statutory services.

The complex difficulties facing
Narayan must be faced by a multi-agency team approach along with support for
the family, enabling her to feel secure in her rehabilitation.

Raj
Jhamat is a National Schizophrenia Fellowship community mental health worker.