Theories to limit chaos

Case study

Situation: Martin Curtis is a 35-year-old man who has just been
admitted to a treatment centre under section 3 of the Mental Health
Act 1983. He has been a persistent drug user since his mid-teens
and was diagnosed as suffering from schizophrenia in his early 20s
for which he is reluctant to take prescribed medication. He has
limited contact with his family who live far away and has few
stabilising influences in the community.  

Problem: Curtis’s lifestyle is chaotic and disorganised. He has
moved home regularly, is normally in debt and is often seen begging
in the local shopping centre. Before his admission to the treatment
centre, he was living in sheltered housing. But he is unable to
return there because of his drug-taking and occasional aggressive
outbursts that have led to police involvement. He has been arrested
for criminal damage and assault three times and is on a probation
order for a number of shoplifting offences. A community mental
health team knows him, but there has been limited input because of
his reluctance to carry out any recommendations. Curtis has also
indicated his intention “to get as far away from mental health
services as possible”. His nocturnal lifestyle has resulted in the
involvement of agencies outside the normal day care services,
resulting in poor information exchange and care co-ordination. What
might the panel suggest?

Panel responses

David Glover-Wright
Martin sounds like the ideal candidate for an assertive outreach
team. He is reluctant to engage with conventional mental health
services and probably feels they are unable to offer him anything
of benefit. He is the sort of individual that the government has
highlighted as requiring more rigorous support and care given his
tendency “to slip through the net”.

At present, Martin could be made subject to a supervised discharge
order or even guardianship order. These measures might help to
organise and frame his care in a more consistent manner promoting
more stability in his life. However, if Martin refuses to engage
with conditions, such as living at a particular address or
attending for treatment, there are no powers available to enforce
his compliance. Supporters of the white paper reforming the Mental
Health Act 1983 might argue that Martin would be an ideal candidate
for a “non-resident” compulsory treatment order that could impose
legally binding conditions enforcing his compliance.

The key issue appears to be working in partnership with Martin.
There is a need to engage with him at his level and establish
understanding of his situation. Workers need to engage in a
non-threatening, creative manner while managing the possible risks
that he poses to himself and others.

Martin has probably internalised his perceived rejection and harsh
treatment and feels antagonised by the authority represented by the
mental health services. Martin’s criminal behaviour appears to be a
direct consequence of his social circumstances and might be
resolved through appropriate housing and financial help.

Martin’s problems are probably compounded by workers feeling
intimidated by his lifestyle and appearance, reinforcing a cycle of
fear and hostility. It takes commitment and resources to break this
cycle. Workers need to support him out of hours in order to build
trust and plan for his discharge. A spell as a formal in-patient
will lead to further alienation and increase the likelihood of
greater disengagement from the system.

There also needs to be a pooling of knowledge and information about
his situation, given the number of agencies involved using the care
programme approach.

Stephen Caffrey
The central question is: does Martin want to change? If
his perception of his circumstances is that he is managing well as
long as the authorities leave him alone, little can usefully be
done until he acknowledges the problems.

It is possible, however, that he is frustrated by constantly having
to evade the authorities. He has an unsettled existence and
probably has a transient, unstructured social network. His
existence bears the hallmarks of learned behaviours that, while
helping him to make sense of his world, also shape an antisocial
existence. His use of illicit drugs may be the only constant
feature of his life, the crutch that gives his life any semblance
of order.

Much needs to be learned about his past. What are the circumstances
that led him to this phase of his life? What do we know about his
family and other relationships and how meaningful are they to him?
What are the key events of his life that carry particular meaning
to him?

I am sure other workers would have pursued these issues with him
but, clearly, relationship-building with Martin will have been
difficult due to his erratic lifestyle. It is unlikely that any
sustained meaningful engagement with Martin has ever occurred; but
that, surely, is crucial to helping him.

A therapeutic relationship needs to be established with a
professional worker, one that facilitates Martin’s ownership over
his life. The relationship should facilitate an exploration of a
meaning for significant events and help Martin to make sense of
current circumstances. He should be encouraged to think about the
sort of future he sees for himself: where are you now and where
would you like to be in a year’s time?

Now is a good time to start because at least he has a stable life
at the moment, will be free from illicit drugs and could soon have
some mental health stability.

I would recommend that a worker with him should be from outside the
hospital, one that can continue in the community and preferably not
be directly attached to the local authority or health authority. A
trusting relationship is essential and it is doubtful whether any
trust can be forged with the authorities that have pursued him and
imprisoned him.

User view

Martin is trapped in a cycle of illicit drug use, mental
illness, criminal behaviour and debt, which cannot be properly
assessed while he continues to refuse psychiatric help, writes
Helen Waddell. The fact that there has been poor information
exchange and care co-ordination is due to so many agencies being
involved and Martin needs a key worker, who can recruit from other
agencies if necessary for cohesive handling of his case. 

But Martin has been unwilling to enter into such a relationship
in the past. However, now that he is being treated under section 3,
a key worker should be appointed. Under section 3, Martin’s
schizophrenic symptoms could be treated with medication. Once he
loses his symptoms, however, he would no longer be sectionable and
may stop taking the medication. 

While still in the treatment centre it should be assessed
whether Martin is suffering from schizophrenia or whether it is
schizophreniform psychosis due to drug use. It should also be asked
whether he is using alcohol. Making a diagnosis inside an
institution may be difficult, as Martin might still have access to
illicit drugs. 

Martin may accept that he is ill and accept treatment once he
has stopped using substances, or he may return to his previous
lifestyle when he is no longer sectionable. This means that,
instead of re-entering the mental health system, he may just as
likely have further dealings with the penal system. Martin is
already on a probation order and a condition of probation may be
acceptance of hospital treatment. Or, if Martin were threatened
with a sentence, there could be a deferral of sentence on the same

Martin will require rehabilitation in the community when he is
mentally stable. A mental health officer, a social worker and a
disablement resettlement officer from the Department for Work and
Pensions should all be recruited by his key worker. 

Martin needs stabilising influences in the community.
Involvement with Alcoholics Anonymous or Narcotics Anonymous may
help. Other self-help organisations, such as the Hearing Voices
Network, may also provide stability. Martin’s relationship with his
family is important and he should be encouraged to build more
contact with them.  Encouragement to become involved with self-help
support in the community is vital if Martin is to find stability,
structure and meaning. 

Helen Waddell is a mental health service

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