Sue and Dave Andrews, both 53, live in an isolated farmhouse with their son, John, 20. The modest farm Dave ran has fallen into disrepair since a back injury caused him to retire 10 years ago.*
Both Dave’s parents, who owned three large working farms, died within a couple of months of each other six years ago – leaving Dave an inheritance which paid off his substantial debts and permits a liveable allowance.
However, most of the family wealth was left to Dave’s brother, Michael, who had managed the large farms with their father. Michael and Dave do not speak to each other. Sue has only ever had a role of home-maker and mother.
Dave had always experienced mood swings but for the past 10 years he has been low and drinks heavily. He has rejected all attempts by his wife to persuade him to see the doctor – and becomes agitated and violent whenever she broaches the subject.
John dropped out of school with no qualifications and lives virtually hermit-like in his bedroom – he is addicted to music, the internet and computer games. He lives a nocturnal existence.
Sue struggles to engage with him – and like his father, John has taken to physically and psychologically abusing Sue. John has also become obese and neglectful of personal care. He says God talks to him each night. Sue has spoken to her GP but neither Dave or John will attend the surgery – and the doctor refuses to visit unless invited by them.
THIS WEEKS PANEL
Milton Keynes – Mental health team
Sarah Dewey – Service user development worker
David Glover-Wright – Approved social worker, senior practitioner
Hannah Minns – Social worker
PANEL RESPONSE 1
This situation is multi-faceted and the various strands need separating out before a definite approach can be decided upon.
John’s presentation gives an indication of possible early psychosis. In Milton Keynes we have a specialist early intervention team who work with young people between the ages of 14 and 25 who may be experiencing a first episode of psychosis.
Initial research has shown that those receiving support and an appropriate medication from early intervention teams had a better prognosis.
The team would be able to be flexible and assertive in their approach to John meeting him in a place where he would feel comfortable. They could begin to build a relationship where he would be able to explore the concerns that have been raised, both by him and other people.
Links could be made with mainstream services. In Milton Keynes we have a “walk in” Youth Information and Support Service which offers free, confidential information and support to young people. The service offers advice on education and employment, which could reduce his isolation.
If John is positive this could be used as a means of engaging with the whole family and would allow time for trust to be built up before approaching Sue’s concerns around her husband’s drinking and mood swings.
Offering each member of the family a carer’s assessment could give an opportunity to look at the whole family’s needs. The role and details of the local Women’s Aid project could give Sue a source of support and, if she chose it, an escape route from the domestic violence.
There are particular issues around working with rural communities. The Rural Emotional Support Team (Rest) in Staffordshire has developed expertise and credibility in farming communities by using respected organisations such as the local church or parish council as a way of gaining trust in communities often suspicious of statutory services.
PANEL RESPONSE 2
In 2001 Chris Philo and Hester Parr published Inclusion and Exclusion in the Scottish Highlands – a research project reviewing mental health needs of those particular communities. This suggested that “mental health problems can lead to stigma and isolation in rural areas due to limited understanding within local communities and inadequate support services”.
The Andrews are isolated and beset with difficulties. Their location, far from being a rural idyll, is their chief tormentor. Limited service provision is the norm for many rural areas in the UK.
With a few noteworthy exceptions the family’s community can at best expect sporadic visits from an overstretched community psychiatric nurse and, at worst, ill-informed advice and out of reach support services.
Rural GP practices can become detached from contemporary mental health practice unless partners have the specialist skills to develop innovative and localised provisions.
The family’s needs are by no means unique; but their problems are exacerbated by their prevailing environmental circumstances. The family system is closed and rigid with poor communication and negative behaviours. Sue is a victim of domestic violence and is seemingly powerless to change her circumstances as she struggles to keep the family going.
Ideally, mental health services would seek to address the whole family situation. A family group conference might assist the family to externalise the negative dynamics and patterns of behaviour and use their strengths to resolve the problems.
This might also introduce some healthy and positive influences to resolve the longrunning feud between Dave and his brother Michael.
John represents a synthesis of all the negative aspects of his family and surrounding environment. He is closed-in and locked out from reality seeking solace in his inner world and cyber space.
The family needs urgent specialist input. All the warning signs are present which presage a major breakdown. Sue is particularly vulnerable while statistical evidence suggests her husband is a high suicide risk with the potent combination of mood swings and alcohol creating a powerful impetus.
Rural Mind published a policy on “Rural Issues and Mental Health” in 2003. It provides an excellent tool kit to develop appropriate services in the countryside. Such a service is vital to the Andrews to help them address their problems and avoid potential disaster.
THE USER VIEW
The challenge for services will be how to engage with a family which has become very insular. The mental health services should not take the well-worn line that they can’t get involved because father and son are not asking for help. There are many people who are in need of support yet need encouragement and reassurance to access help on offer. Frequently, people have had negative experiences of services in the past and are wary of getting involved.
Various strategies could be tried to engage with the family. The farm has fallen into disrepair. So, in the first instance, practical assistance could be offered, possibly through a voluntary sector organisation, to help Dave with the farm. This could be employing someone to work on the farm, gaining a financial grant or business advice for example.
Similarly, with John, time and effort should be put into establishing a rapport with him. His music interests could involve going to a gig, taking a course or starting music therapy. As a relationship develops, attempts can be made to engage John in thinking about his health and social well-being.
The needs of Sue should also be considered. Although there are health and social difficulties within the family, Sue should be made aware that she does not have to put up with physical or psychological abuse from her husband and son.
However, she may lack confidence in dealing assertively with the situation. Various options could be discussed with Sue, making sure that she feels in control and without upsetting the fragile stability of the family. Help could be offered to build up her self esteem, increase her assertiveness and develop an outside life.
The approach with the family is likely to take time, requiring creativity and perseverance. However, having established a good relationship and with an approach based on respect and self-determination, it is possible that Dave, Sue and John will be able to achieve lasting improvements in their lives.
Kay Sheldon is a mental health service user
* Family members’ names have been changedThis article appeared in the 2nd August issue, under the headline “Isolated and at odds with each other”