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People with mental health needs can prove difficult to engage with effectively. A common root cause for this is a strong distrust of authority. Thus simple engagement tactics such as finding informal meeting places and so on have to combine with stronger methods of building up trust and relationships.

Young people suffering from an episode of psychosis, which is a loss of contact with reality, can experience disturbing thoughts, delusions or hallucinations leaving them confused and distressed. Escalation of anxiety in social situations, a common feature of psychosis, provides a further obstacle to accessing support. The quicker these symptoms can be understood and treated the greater chance of their elimination.

Such difficulties were faced by care co-ordinator Sue Devonshire in the case of 24-year-old Andrew Murray, who was suffering a first episode of psychosis and hearing voices constantly and experiencing delusional and paranoid thoughts. Indeed, the difficulties faced in engaging with Murray were heightened because of his homelessness. As he could not be contacted by visit, phone or letter, all contact had to be motivated by Murray and he found it difficult turning up to meetings on time or at all.

Early contact by Devonshire and her colleagues was very informal because of Murray's unwillingness to trust authority figures. "We began by trying to secure safe and appropriate accommodation for him," says Devonshire. "This was a difficult and time-consuming process. He was caught up in a cycle of mental health issues that disrupted his accommodation and vice-versa."

As well as sleeping rough, Murray had at times stayed at local authority hostels. However, these stays had proved even more traumatic as other residents, usually older, shared "an equally chaotic lifestyle," says Devonshire, "with drug and alcohol misuse".

Nonetheless, Murray would often pop into the youth service centre as it provided a warm, non-threatening, youth-oriented environment and, of course, other people of a similar age to meet and chat with. The drop-in nature of the centre suited him.

Devonshire used these visits to foster trust with him. "We ensured that he was able to obtain food, receive help with money and obtain support and insight into his psychotic experiences," says Devonshire. "Our initial approach, which helped him to sort out practical issues, increased his trust of workers and his willingness to engage more fully. He was clearly struggling with stuff internally but we gave him the time and space."

One day, Devonshire found him unsure whether to finally talk about his experiences. "So, I just said, 'I'll be here for the next two hours or so. If you want to talk, I'm here'. And a little later he knocked on my door," she recalls. Two hours of traumatic and often delusional thoughts and ideas followed. But he was finally engaged.

Murray began talking more about his delusional ideas and thoughts. Devonshire coaxed him to consider the benefits of seeing the centre's in-house psychiatrist. Murray, despite deep-rooted concerns about side-effects and associated stigma, also considered anti-psychotic medication.

"Getting to the initial meeting with the psychiatrist was no mean feat," says Devonshire. "At first, he would only see the psychiatrist if he felt sufficiently unwell. The team was conscious of treading carefully in order not to scare him off and risk losing contact."

But with consistent support and encouragement Murray finally began sessions with the psychiatrist. The youth-friendly approach and environment of the centre was pivotal in this success. Murray, understandably, remains uncomfortable with the idea and practice of the sessions, but does now recognise the personal benefits that have resulted.

Things are now falling into place for Murray. "He now has a care plan," says Devonshire. "He is aware that this will not be an easy transition for him. We are working on his identified goals for the immediate and long-term future. These include finding appropriate and meaningful training or employment and increasing his social opportunities."

Significantly, Murray moved into permanent accommodation -Êa supported housing scheme, with staff on call during evenings and weekends. This was again achieved through a patient, time-consuming process, so indicative of the team's approach.


"He sees this as an opportunity to put down some roots," says Devonshire. It could well be the anchor required to bring stability to the chaos and turmoil that has characterised his life so far.

Case notes

The name of the service user has been changed

Practitioner: Sue Devonshire
Field: Care co-ordinator, mental health
Location: South west England 
Client: Andrew Murray is a 24-year-old white male who experiences delusional and paranoid thoughts accompanied by constant voices.
Case history: Murray has a history of sleeping rough on the streets or in parks. At points of crisis he would stay in local authority hostels and had recently slept on a friend’s floor, but his friend had been taking nearly all Murray’s benefit entitlement to pay for this. His accommodation breakdowns would often see Murray seek help from a popular youth services centre, which offers support, information and counselling. Workers at the centre were increasingly concerned about Murray’s behaviour as were the mental health team, also based in the centre. Contact was kept very informally at first as the team did not want to scare Murray off. They realised that time and patience were the best route to engaging Murray effectively.
Dilemma: It was clear that Murray needed to talk about his distressing experiences but the team knew that he had to come to them and had to be patient.
Risk factor: Murray was clearly at risk but he deeply distrusted people he considered to be in authority and any attempt to engage him professionally would potentially put him at greater risk by resuming a life back on the streets.
Outcome: Murray now has an agreed care plan and is in appropriate supported accommodation.

Independent comment

This case illustrates the dilemma that can be faced by all services when a young person experiences a first episode of psychosis, writes Eric Davis. The response provided by Sue Devonshire and her team is to be commended.
Engagement is crucial to making progress. Because practical issues such as a place to talk to other young people, accommodation and budgeting skills were provided, further psychological and medical issues such as the nature of the psychosis and details of symptoms could be addressed, and psychological therapies and medication also considered.
However, the issues of engagement and the time required to secure such engagement are pivotal. If for any reason, this engagement could not have been secured, then Devonshire would be faced with a dilemma: whether to invoke use of the Mental Health Act 1983 in the case of serious psychological or psychiatric disturbance. If the need for such a choice arose, hard-won trust and confidentiality would be jeopardised.
Nevertheless, the work with Murray exemplifies a sound, creative and youth-friendly approach that appears promising in terms of improving the lives of young people developing first-episode psychosis. The emphasis upon developing a service which is responsive to the specific needs of young people with psychosis is to be applauded.
Eric Davis is consultant clinical psychologist with the Gloucestershire NHS Partnership Trust, and south west regional lead for early intervention in psychosis. Visit www.iris-initiative.org.uk