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Case notes

Practitioner: Chris Coates, team leader, rural emotional support team (Rest). 

Field: Mental health services for adults in rural communities. 

Location: Staffordshire. 

Client: Eddie Burdett, 31, is a farmer who runs a beef herd for his father - who himself runs a 500-cow dairy herd.  

Case history: Burdett was the only sibling to move into farming and resents the amount of support his father gives to the others. He began drinking very heavily, was depressed and angry and began acting aggressively. He also threatened to take his own life. Following a mix-up with the paperwork for his animals' passports (which all cattle must now have), Burdett received a summons from the Department for Environment, Food and Rural Affairs (Defra), which intended to prosecute him for fraud. Fearful of losing his farm, Burdett was referred to Rest by a worker at the Rural Payments Agency (part of Defra) who knew of the team.  

Dilemma: Although in need of services, Burdett, as part of a traditional farming family, would see any such "outside help" as a failure and a slur on the family name - as, importantly, would his father. 

Risk factor: Working with Burdett at home rather than in hospital meant he might take out his drunken anger out on someone or, indeed, carry out his threat to end his own life. 

Outcome: Burdett's drinking is under control and his relationship with his father is slowly improving. There have been no further threats to commit suicide.

Seeking parental approval without achieving it can have devastating consequences. Some people, such as Eddie Burdett, work hard for recognition, respect and love but end up feeling that nothing they do is good enough. His emotional rejection by his father led him to depression, aggression and thoughts of suicide.

Burdett had always worked in farming, dutifully carrying on the family tradition. While his siblings were seemingly well supported in their new lives, Burdett - who was paid only £60 a week by his father - felt he was the brunt of all criticism. Following a paperwork mix-up, he received a summons from Department for Environment, Food and Rural Affairs and a demand to repay £4,500. The amount would ruin his business and he'd fail. Just as he suspected his father always knew he would.

His drinking became dangerously heavy. "He was up to 34 cans and nearly 100 cigarettes a day," says Chris Coates, team leader of the innovative Rural Emotional Support Team (Rest), which targets mental health services for the traditionally difficult-to-reach rural community. "He had huge anger problems and was extremely volatile. He was threatening neighbours with violence, saying he was going to kill them and then himself." Burdett wore his loneliness and low self-esteem as sackcloth. "He couldn't see any good points in his life," says Coates.

Initially, hospital was an option. However, for Burdett "outside" care services were a sign of failure. He would not even see his GP, who was a family friend and who had delivered him as a baby. Indeed, Coates had to pretend that he was working on Burdett's house so that nobody suspected he was meeting mental health workers.

"By going to hospital, it makes it public that there's something wrong with the family. Economic, health and emotional problems are kept behind closed doors," adds Tom Dodd, chairperson of the advisory group for Rest and the team's clinical supervisor.

Unsurprisingly, then, Burdett refused hospital. "He said, 'Who would look after my farm? My dad won't because he's waiting for me to fail - and I won't allow that.' So, even though he wanted to harm himself, he was indicating that he wouldn't give in," says Coates, who also knew Burdett would need medication because of his consistent low mood - a depression clinically beyond that induced by alcohol.

Burdett agreed to see Coates daily, and they both kept in touch via mobile phones and text messages, which, along with his mother's consistent presence ensured that Burdett always had someone to turn to. "We focused on getting him to recognise his role and value on the farm," says Coates.

The father-son relationship soon revealed itself at the root of Burdett's problems. "We ended working with the whole family, dealing with issues that probably stemmed back to his dad's treatment of him in early childhood. And yet his dad's life had been a mirror image. His rationale was 'Well, it hasn't hurt me', but he can't see the damage he's doing to his son," says Coates.

He continues: "We suggested that his dad tell him what he wants - because in private he was telling us different things. His dad would tell us that he loved his son to bits and believes he will be a very successful farmer - so why not tell him that?"

"This was one of the first times the team did more structured family work," comments Dodd. "It gave them an opportunity to speak to one another in a way that wasn't destructive." It helped highlight a pivotal role for Burdett's mother. "She had been colluding with them both to keep the peace. But through the family sessions this small, meek and mild woman emerged as the family's kingpin."

With his mum on board, Burdett's drinking and smoking reduced to a couple of cans and 20 cigarettes a day. "Although still volatile at times, Burdett identifies early signs and copes well. Or he just gives us a call. What he doesn't do now is isolate himself and become angrier and angrier. We've even got him to see his GP, and he's now working well with the drug and alcohol service," says Coates.

The contribution of the Rest team remains, with fortnightly formal family work and weekly visits to Burdett, sometimes more. "He is putting all the time required aside, and is not letting the farm get in the way of his own well-being," says Coates.

Arguments for risk 

• Hospital would have reinforced a belief that he "was a lunatic who's going to kill somebody and who needs locking up. We may also not have got him out for a long time. He has no rights to the farm - and his dad would have sold it. Once out of hospital, there would be no role for him," explains Coates. 
• Coates was able to show how the family could talk constructively rather than their conversation breaking down into arguments. The move was a critical turning point in getting people to share responsibilities. 
• The pressures on increasing the risk centred on relationships, environment and situation, which on the surface appeared inflexible. But by working with everyone, Coates started to change those dynamics. "While you have the clinical approach, the solution doesn't have to be clinically led. It's worth taking the extra time to look at the social and environmental impacts in assessing and managing risk," says Dodd.   

Arguments against risk 

• There was a distinct possibility that Burdett - who was volatile, threatening and aggressive - would harm either himself or others. The team visited daily and kept in touch by telephone. Burdett's mother was also around to prevent him feeling isolated. However, his sense of isolation had already existed even with his mother's presence. The team's protective measures may have been compromised by his excessive drinking. 
• Given his drinking habits, he would also put himself and others at risk if he were to use his tractor or other farm machinery or tools when drunk. There was also the risk that his drinking might accelerate rather than moderate, thereby irreparably damaging his health through alcohol abuse.  
• An enormous stigma was attached to using outside care services, but surreptitious provision of these services could not be prolonged. It would surely get out, with all the attendant consequences that that might bring to Burdett's already troubled self-esteem.

Independent comment

This is a good example of how a team using an assertive outreach approach can engage and support people with mental health difficulties who don't seek out help because of stigma, writes Toby Williamson. The team also showed how well it adapted to an individual's complex needs, and worked with the person in their own environment. It also worked sensitively with the person's social network to promote trust and engagement. This was all done creatively and subtly, and importantly met all of Eddie Burdett's needs - social, economic and emotional - rather than just dealing with the mental health problem.  

They used an eclectic approach, working with Eddie on his problems in his environment, rather than removing him and isolating him in hospital. In choosing this route, Rest showed that persistence that builds a trusting relationship rather than coercion can pay off in the long term. A good example was that by pretending to work on the house, Chris Coates showed Eddie that the team was sensitive to his needs, and could listen.   The team reduced any risk by engaging with the family and keeping in regular contact. The decision not to put him into hospital was correct, as in the long term he could have come to distrust services, having had his wishes overridden and been coerced into treatment.  

This is assertive outreach at its best. It is about constructive engagement, patience and persistence, not coercion.  

Toby Williamson is head of Strategies for Living at the Mental Health Foundation. www.mhf.org.uk