Case study 
The names of the service user and her husband have been changed

Situation:
Noreen Lewis, 59, lives with her husband, Michael, 63. They are both retired professionals. Noreen has a diagnosis of bipolar affective disorder (also known as manic depression). This is a disorder characterised by extreme swings in mood, from high to low, from depression to elation and over-activity (mania). She acknowledges this but is very anti-medication. An aromatherapist and herbalist, Noreen has told the community mental health team (CMHT) and psychologist that she no longer needs their input as they are preoccupied with conventional medication and treatments. 

PROBLEM:
The marriage is failing and Noreen's mental health is deteriorating. Michael and the psychologist collude and are convinced that the  marriage will be fine if Noreen takes her medication. However, again she refuses and Michael requests a Mental Health Act 1983 assessment. The CMHT and crisis resolution team are convinced she needs hospital in-patient care and are not prepared to look at community support options as she is "non-compliant" with medication. Noreen is adamant she does not want to go into hospital (having had a distressing time previously) but will accept treatment (St John's wort - a herbal antidepressant) and community support if mental health services understand her perspective. They refuse and Noreen is sectioned under the Mental Health Act. Noreen is now presenting many challenges in terms of after-care and support for the community services.

Practice Panel Mental Health Team - Milton Keynes
Steve Caffrey - team manager, community mental health team ; David Glover-Wright, team manager, CMHT ; Kathie Price, community psychiatric nurse, CMHT ; Jane Ross - community psychiatric nurse

Panel responses
Steve Caffrey
Working with someone with bipolar affective disorder is widely accepted by practitioners as a challenge. It is often stressful for those involved. Add to this a strong family dynamic and it is hardly surprising that practitioners and family members are vulnerable to "collusion", which can only damage any semblance of trust.

The challenge now for practitioners is to establish a trusting relationship from which to negotiate and implement an aftercare plan that is acceptable to Noreen. It is likely she has no faith in the multi-disciplinary team and in her husband. She feels betrayed.

A decision about the key worker is central to an effective aftercare plan. What role will Noreen have to choose the key worker(s)? Good practice means having a co-worker involved, peer supervision and strong management support. The multi-disciplinary team needs to be focused, supportive of each other, positive and creative. And it will need to prepare for the long haul: there is no quick fix.

Presumably, the hospital treatment will have achieved some stability in Noreen's mood. In theory then, she should be well enough to participate in aftercare plans. Any negotiation seems to hinge on whether the medics will agree to her use of St John's wort. In fact, she does not need permission: it can be bought over the counter. There have been clinical trials that support the use of St John's wort in the treatment of depression, but it is not a mood stabiliser and it will be difficult to engage with Noreen if she is unstable.

In any event, medication is only part of the answer and possibly even a red herring in this case. Her view on powerful modern drugs is not unreasonable and must be respected. Serious consideration should be given to other treatments like cognitive behavioural therapy. A collaborative, guided discovery and educational style of cognitive behavioural therapy could be more valuable for Noreen if she wants to take an active part in her therapy. Thought should be given to including her husband in a therapeutic plan because there are obvious complexities and tensions in their relationship that will impede any progress if they are not addressed.

David Glover-Wright
Noreen's situation is by no means unique. There are many people who are reluctant to engage with conventional mental health services, having justifiable fears about the side effects of powerful "antipsychotic" medications. They are also concerned that they will not be regarded as individuals with their own unique understanding of their mental health needs.

Contemporary mental health services are still struggling to break the circle of fear that exists for many people faced with the prospect of ongoing contact with psychiatry. Recent research undertaken by Mind has highlighted that people's experiences of in-patient care are often negative. 

Patients often feel they gain more support and help from their fellow in-patients than they do from professionals. Noreen might have seen her psychiatrist weekly in large formal team meetings. She might have had little opportunity to share her concerns and anxieties with nurses who could have been concentrating on the more disturbed and "difficult to manage" patients. An acute in-patient ward can be a frightening place, offering limited opportunities to address underlying mental health needs. 

The assessment team probably believed there was little alternative and felt constrained by the risks had Noreen not been admitted. Few areas in the country have viable alternatives to acute in-patient care. Noreen might be an ideal candidate for a non-statutory therapeutic environment where her wishes to receive alternative means of treatment can be respected. Professionals should acknowledge that Noreen has insight into her mental health needs and a willingness to find solutions to her problems and should move away from reactive, short-term fixes. 

The challenge now will be for professionals to help Noreen regain confidence in the mental health services by showing a willingness to meet her halfway. Her community key worker will need to start regular visits while Noreen is an in-patient and begin listening to her views on how she wants to move things forward. 

It seems a seismic shift is needed to enable Noreen to occupy a central position in her treatment rather than being consigned to the periphery. A service user advocate might assist Noreen in the long process of regaining control over her life.

User view 
The services need to make a much greater effort to understand Noreen's perspective, writes Kay Sheldon.

Health and social care provision is supposedly based on individual needs and choice. The professionals involved in Noreen's care have the opportunity to make this aspiration a reality. Noreen is clear about what she does and doesn't want and this should form the basis of her care package. 

Most mental health interventions, including medication, have a weak evidence base. Much of the research has produced results that are either inconclusive or cannot be generalised. 

Noreen's desire to use herbalism and aromatherapy should not be viewed as less valid than the typical medication-and-psychology combination that mainstream mental health services are offering.

Psychiatric medication works for some people but for many others it is an unacceptable option, usually because of the horrendous short- and long-term effects it has on a person's psychological and physical health. If doctors and nurses were made to sample the medication they prescribe and administer, they would think twice about prescribing it. Antipsychotic drugs and mood stabilisers in particular have nasty side effects, including lethargy, shaking, restlessness, weight gain and blood disorders.

Noreen is being honest and open with the mental health services, something the mental health professionals should value and build on. Noreen needs a psychiatrist and community mental health team which is willing to think beyond their professional constraints. 

Advice should be sought from experts in herbalism and aromatherapy, so the options can be discussed with Noreen. Her husband should be fully involved and is likely to have to overcome his expectation of services, just as the professionals will. Collusion between Noreen's husband and members of her care team is unacceptable.

A range of strategies should be explored with Noreen and her husband which could be a combination of alternative or complementary ones alongside more conventional ones, such as self-management, relaxation and identifying "triggers" and early warning signs. 

Direct payments should used if necessary to fund any services that are not available from the health or social care services. The professionals involved in Noreen's care should approach it with a view to making it work, rather than believing it will fail. 

Kay Sheldon is a mental health service user