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Case study

The name of the service user as been changed.

Situation: Mehreen Ahmed is a 50-year-old widow living with her 15-year-old daughter Shefali in a council home. Since her husband died four years ago, she has twice been admitted to hospital under section 2 of the Mental Health Act 1983. She has been variously diagnosed as suffering from paranoid schizophrenia, bi-polar affective disorder and depression. There is currently no contact with mental health services, although she visits her GP fortnightly for depot medication.

Poblem: Mehreen has three older children (two daughters and a son) who live away from the family home. The daughters have both had children outside wedlock incurring the disapproval of other members of the local community who share her cultural background. Recently, Shefali has been spending time away from her home and police have notified the local children's team that she has been found staying at the home of a known drugs dealer. Mehreen has been making 999 calls to the police that have been difficult to understand because of her poor English. She has been reporting her daughter as missing and has been asking for help. The police have described her as "mad". Recently, her oldest son requested a mental health assessment for Mehreen, and despite her cultural isolation, both doctors (one of which was her GP) signed a medical recommendation supporting her compulsory admission. The approved social worker, however, is not so sure.

Panel responses

David Glover-Wright
Mehreen Ahmed is a highly vulnerable person given the loss of her husband and the subsequent need to make headway in an indifferent society. Her attempts to gain help for her daughter are met with incomprehension; her attempts to gain help for herself are met with a depot injection and medical recommendations supporting compulsory admission to hospital.

Her daughter is probably responding to the emotional instability within the family and replaces it with ever more risk-laden and vicarious activities. Mehreen is caught in a vicious circle of oppression. The more distressed she becomes the "madder" she seems. Her family respond to their mother's needs by either becoming more extreme in the rejection of their cultural norms or more reactionary in terms of attempting to medicalise her situation. The son is perhaps assuming the role of head of the family and realises his mother needs help and support, and turns to the services to provide this, not knowing the potential damage it might cause.

Mehreen must feel trapped in her situation. She needs an advocate to assist her in gaining access to children's services and help her understand the mental health system. My guess is she does not even know she has been diagnosed as suffering from the three disorders let alone appreciate the impact these malicious labels have on her situation.

The approved social worker (ASW) has realised a further admission to hospital probably would not assist in resolving her situation. The chances are she would be admitted to an in-patient unit where there would be highly disturbed individuals causing her further distress and reinforcing her feelings of isolation given the culture barriers. The ASW needs to have other "least restrictive" alternatives to turn to. A specialist support worker familiar with Mehreen's cultural needs would be an ideal start.

The crisis situation represents an opportunity for change. These could be harnessed by skilful intervention and propel Mehreen in to a more stable situation. Both her oldest and youngest child might then recognise her greater stability. And with continued support, Mehreen could re-establish more harmonious relationships, avoiding prolonged contact with mental health services.

John Cash
Mehreen Ahmed's troubles are aggravated by the failure of support services to acknowledge her cultural, language, and mental health issues. The mental health services appear to have made various unhelpful diagnoses, instigating a medication regime and ignoring her wider situation. Medication on its own is not the answer here.

An experienced practitioner with a good understanding of the cultural issues needs to engage with Mehreen enabling her to regain confidence and self-belief. Such a professional might be able to engage with her on different levels and undertake some meaningful work. At the very least, an interpreter should be used given Mehreen's difficulty with English.

The allocated worker should assume a level of responsibility within the legal framework and involve the wider services in appreciating the need for ethnically sensitive practice. Without this commitment, the allocated worker will be working in isolation.

Consideration should be given to Mehreen's older children, and acknowledgement made of their difficulties. A social systems approach might help in understanding the various problematic relationships in the family. Good practice suggests effective links need to be in place between mental health and children's services enabling effective co-ordination to take place in response to Mehreen's concerns and anxieties about Shefali.

It may be possible for the older children to offer support to their mother and her younger child. However, they might be wary of engaging with the statutory services perceiving them in a negative manner. Her oldest son is clearly concerned for his mother's situation and needs to be brought in to the planning process, should Mehreen be agreeable. The family need sustained support if stability is to be regained and Mehreen's dignity and respect is to be reinstated within the family and community.

There are a number of different levels of need in Mehreen's situation. A family meeting with children's service workers might help establish where the level of need is most acute. A combined approach is required with all services co-operating to establish common goals and objectives. This will prove difficult given the closure created by the actions of the doctors and professionals previously involved in her situation.

User view

If Mehreen Ahmed's approved social worker is not sure about compulsory admittance then an alternative care plan must be formulated and this means a multi-disciplinary reassessment is necessary, writes Helen Waddell. Mehreen's GP and social worker, and a psychiatrist, are already involved, and a keyworker - perhaps a community psychiatric nurse (CPN) - should be appointed. 

It is essential that Mehreen can build a relationship with this person. Mehreen could visit a day hospital or a day centre with psychiatric input, and a CPN could accompany her on these visits. 

Mehreen has been variously diagnosed in the past and her illness possibly involves psychosis or mania. Statistically, however, it is more likely to be a depressive illness. The possibility of psychosis does not necessarily mean compulsory admission as most patients with psychotic illnesses who are admitted and treated in hospital do so informally. 

Mehreen's illness may have been precipitated by an adjustment reaction to the death of her husband four years ago. This is a relatively short time in which to deal with grief and loss.  Mehreen is suffering alienation in multiple forms. She has moved from her own country to an unfamiliar environment where she is unable to communicate effectively. She is alienated from her own ethnic group owing to the shame and stigma associated with her older daughters. And because she is suffering from a mental illness she is subject to stigma and alienation from both her host and own ethnic cultures. Mehreen clearly needs an interpreter because of her difficulty with English. 

Following assessment, the care plan must be carried out by Mehreen's keyworker who will be at the centre of a multi-disciplinary network.  

The severity of Mehreen's condition suggests it may be up to three years before she is completely readjusted. For this reason, her care plan must look at with short, medium and long-term aims. 

To start with this will involve crisis intervention. Mehreen's dependency needs must be met and help given with decisions until she is well enough to take back full control over her life. She must be kept involved and informed throughout this process and it must be communicated clearly that solutions are possible.  

Once Mehreen's mental health starts to improve, her younger daughter, Shefali, may be less inclined to spend time away from home. 

Helen Waddell is a mental health service user.