Situation: Tina Rose, 76, lives with her 42-year-old daughter, Val, who has long-term severe mental health problems. She has spent about 15 years in the local psychiatric hospital but was discharged into her mother’s care five years ago, in keeping with the care in the community policy, when the hospital closed. Val receives support from the primary health care team, in particular a community psychiatric nurse and a social worker. Val also attends a day centre once a week. Tina and Val seem to be coping with this level of support.
Problem: Tina Rose has become increasingly frail and her behaviour has been causing her son, John, 45, concern. After an initial medical assessment, the GP told John that her mother was developing dementia-related symptoms. John is aware of what this might mean for his family but is finding the possible future care needs of his mother and sister difficult to come to terms with. He lives in the same neighbourhood with his wife and two teenage children. John’s wife refuses to become involved and any attempt to discuss the situation ends in serious argument. She has threatened to leave him if he once more suggests that his sister might have to live with them. John has started to drink heavily. The family doctor has noted some physical changes in John’s appearance, and a routine check-up has shown that John has high blood pressure.
This situation seems complex and fraught with problems. Several people could be identified as potential “clients”. However, the situation appears to have reached crisis through problems originating away from the expected source.
A worker presented with this situation needs to stop and reflect on the variety of issues being presented. Analysis of presenting behaviours will begin to establish an array of needs. Most do not seem to centre on Tina Rose and her daughter. Both are reported to “be coping”, while John is becoming increasingly animated in his behaviour.
His relationship with his wife seems to be fragile and inflexible. The change threatened by the apparent deterioration in his mother’s mental health has shaken his social system to its foundations. His anxieties mount as he envisages his sister moving in and his mother “put away” in residential care. He is unable to share his anxieties and takes refuge in drink, which enables him to vent his emotions but lessens his ability to cope. He is then caught in a vicious circle of self-recrimination and blame.
A can of worms could be opened by intervention. A worker might find themselves overwhelmed with the complexity of the situation and be unable to assist in a constructive manner.
It could be that Tina’s situation is deteriorating. With help from the local elderly mental health services her situation could be stabilised and her daughter assisted in maintaining her situation with carer support. The GP’s “diagnosis” needs checking out and a referral made to an older people’s psychiatrist for a more thorough assessment. An accurate assessment of any cognitive deterioration will help in making plans for Tina’s needs. Good communication is needed between the adult and elderly mental health services.
Applying a systems approach seems relevant. John needs assistance to see that his rigid expectations and poor communication are leading to stagnation, recrimination and instability. He needs help in developing more positive coping strategies. However, this will only happen when he is willing to explore some of the issues affecting his wider family situation.
Despite the likelihood that Tina has dementia and is becoming frail, the indications are that Tina and Val’s home circumstances are stable. Neither of their care needs is presented but, on the understanding that Val is known to the primary health care team, I would suggest an assessment of Tina’s needs by a specialist dementia social worker. This would help to establish her mental health and physical needs, potential risks, any role she has as Val’s carer and her ability to continue caring.
It could be helpful for John to be included in the assessment. In so doing, John might feel that he is making a valuable contribution towards his mother and sister’s care. It might also help to define some practical ways he could continue to support them without the thought of his sister moving in with his family. It is not known whether his sister would even want this to happen.
It is possible, however, that John is in denial of personal and family circumstances and could be using his mother and sister’s situation as a convenient screen to hide the causes of his own anxieties.
Changes in John’s physical appearance, high blood pressure and heavy drinking suggest that there have been some events, recent or distant, that have contributed to his current condition. The situation with his mother and sister might have been the trigger that set off his anxiety.
My first thought is that counselling would help John to identify and come to terms with any underlying personal and relationship or marital issues. Little information is given about John and his wife’s relationship, or of her explanation of John’s emotional and physical changes. It might be useful to consider whether John and his wife would benefit from joint counselling.
Some information about John’s drinking would help to define the degree to which he feels it might be a problem. When did he start drinking “heavily”? What is he drinking, how often and how much? To what extent does he acknowledge the effect his drinking might be having on his perception of his life circumstances? John’s drinking is likely to be a part of his vulnerable coping system that helps him to forget, and therefore to deny, problems.
The feelings and opinions of Val are not mentioned, writes Kay Sheldon. There is a tendency to overlook the fact that people with severe mental health problems have views and concerns, often because well-intentioned people don’t want to worry us or they think we’re not interested. The same is true for Tina. Even if no one has told her about her possible diagnosis, she will be aware that things are not right. Both Tina and Val need to be involved in the discussions and decisions about their futures.
John seems to be taking his family responsibilities seriously, which seems to be having a detrimental effect on his health. High blood pressure and heavy drinking are likely to be stress-related. I feel his GP should take a proactive stance by discussing with him options for managing his stress, such as relaxation, counselling or exercise.
I think the key to this situation being managed successfully by health and social services is good communication, both with the different family members, including John’s wife and children, and between the various services. At some point, Tina will probably have some input from the mental health services, and it will be important for them to link up with the professionals involved with Val’s care as well as liaising with John, assuming both Tina and Val are happy with this.
Val should be involved with the planning of her future, with input from the local mental health advocacy service if she would find this helpful. The option of going to live with her brother should be discussed to establish whether this would be her preference and, if so, whether it could be achieved in a way that was acceptable to John’s wife.
Options such as supported housing or a residential home should also be explored. Val might also want her own place with appropriate support. Whatever is decided, it is likely to take time to organise, so needs to be planned well in advance.
Another option the family might want to consider, for both Val and Tina, is direct payments, which would allow them to buy and organise their own care and support. The family would need to discuss this with a social worker or another expert to establish what would be involved, and if it would be the right choice for them.
This is a stressful family situation for everyone involved but, with good communication and support as well as adequate forward planning, the impact on those involved could be much reduced.
Kay Sheldon is a mental health service user.