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Case study

The name of the service user mentioned in this article has been changed

Situation: Callum Proctor is a 22-year-old black male who experiences delusional and paranoid thoughts accompanied by constant voices. He has a history of sleeping rough on the streets and in car parks. At points of crisis he would stay in hostels where he would often be picked upon, bullied and punched. However, he would return for companionship and to get drunk and occasionally smoke cannabis – which served only to heighten his delusions.

Problem: Callum, who cannot bear any authority-type figure and has never engaged with social or health care services, occasionally uses a voluntary sector mental health drop-in centre which provides support, information and counselling primarily aimed at younger people, but which has a good reputation as a place to hang out. As he looked young for his age he was able to fit in and staff didn’t bother him much. However, he felt able to disclose to a youth worker that he had stayed at a hostel where he had been beaten up (“because they think I’m mad talking all the time”), sexually assaulted and robbed by three men whom he thought were about 50-years-old. He hadn’t reported anything because he didn’t want to get into trouble and, anyway, who would believe him? He didn’t want to go back to the hostel because one of the men said he was a pimp and he would force Callum into the sex trade.

Practice Panel: Milton Keynes primary care trust
Panel Members: Kathie Price - communitypsychiatric nurse, community mental health team ; David Glover-Wright - team manager, community mental health team ; Steve Caffrey - team manager, community mental health team ; Jane Ross - social worker, crisis resolution team ; Kate Vaughan - substance misuse outreach worker, Addiction Counselling Trust

Panel responses

Kathie Price
If the drop-in centre made this referral to us it would be dealt with by our community mental health team duty service.

As duty workers, my colleague Jane Ross and I would want to be sure that his permission had been sought to discuss his needs with us. If the centre worker told us he had a fear of mental health services and didn’t want our involvement we would be left with a dilemma. He has a right to privacy and to refuse our involvement. However, it could be decided that he is lacking capacity and we have a duty to act in his best interests given the high risk issues. 

We would need to judge the level of involvement and commitment from the drop-in centre. They could be encouraged to take Callum to accident and emergency to see the duty community psychiatric nurse. We are aware that it is not always appropriate to attend A&E with acute mental health needs, given the often hectic and chaotic environment. Milton Keynes is currently developing a walk-in centre and self-referral service to enable better access and give people more control over their situation.

If Callum is prepared to see us we would undertake an urgent duty appointment at the drop-in centre. The drop-in worker could act as his advocate and support him in expressing his needs. We would want to establish a rapport with Callum and gain his trust. But statutory mental health services are sometimes perceived as posing a threat, particularly to people from ethnic minorities. We work closely with voluntary groups in our area and try to promote better understanding about mental health issues.

If we are able to undertake an assessment we could then involve our crisis resolution team. They in turn could use our “easy access bed” which is in a Richmond Fellowship-run hostel. This would avoid possible placement out of Milton Keynes in B&B accommodation.

It could be that Callum’s mental health needs are too acute to manage in a community setting. His mental health problems seem to be exacerbating his vulnerability and he is caught in a downward spiral of risk. We would try and avoid admission but this might be necessary if his risks continue to escalate.

David Glover-Wright
Callum is a highly vulnerable young man at risk from those around him. He is an easy target for unscrupulous individuals and has little defence against those seeking to abuse and exploit him. To the public he must seem a strange and sometimes frightening person troubled by disturbed thoughts as he flits between his external circumstances and his inner world of delusions and paranoia.

As a black man Callum is three more times more likely to be detained under the Mental Health Act 1983 than his white counterparts(1) and has learned to distrust services that usually emphasise medication and compliance while denying individuality and cultural identity.

Yet there is hope in his seemingly desperate situation. He has made a connection with a drop-in centre, which could combine its own expertise with statutory authorities.

Our assertive outreach team (AOT) seeks to work with voluntary support services to reach out to people like Callum and work with them on their terms. Through careful nurturing of contact it might be possible to help Callum focus on some of the risk issues in his life and help him to see the benefits of putting protective measures in place to keep him from harm. 

Any attempt to work with Callum must be at his pace, harnessing his skills and strengths and helping him to establish new personal qualities enabling him to start moving forward. This work needs to be co-ordinated and the back-up and support of an AOT is necessary. An AOT also has the advantage of close working ties with the local housing department. Our AOT has a specialist housing worker who can help pave the way to supportive lodgings through contacts with housing officers and housing associations.

Callum also needs to know how to steer clear of the sharp end of statutory mental health services. A Mental Health Act assessment could easily be requested. He has enough insight to avoid this option but needs the time and care to gain some stability in his life. In the meantime, many risks could eclipse this process and will need to be constantly reviewed with Callum.

(1) Count me In Census, National Institute for Mental Health England, November 2005

User view
Callum experiences delusional and paranoid thoughts which are exacerbated by his alcohol and cannabis use, so it has to be considered whether the sexual assault he reported to a youth worker is a delusion, writes Helen Waddell.

But it must not be presumed this experience is a delusion just because Callum suffers from psychosis. He is extremely vulnerable because of his psychiatric symptoms and lack of proper housing, and could well be subject to attack. Even if Callum’s complaint does turn out to be delusional, whoever is working with him must have an understanding of the kind of psychological effect this is likely to have and have due sympathy.

The youth worker to whom Callum disclosed could continue to develop a therapeutic relationship with him to allow investigation into the claim.

Callum seems to be more comfortable with voluntary services. He could be introduced to a voluntary service from which a worker could accompany him for a psychiatric review, as he is highly unlikely to engage with services himself.

The drop-in centre is not aimed at Callum’s age group, and the youth worker to whom he disclosed could introduce him to a more age-appropriate service, accompanying him initially. It may be beneficial to introduce him to an ethnic minority project, where there would be more awareness of cultural influences upon his mental health.

The main obstacle to Callum’s recovery is the issue of distrust. Trust must be established with a sympathetic mental health worker before psychiatric intervention can begin. Voluntary and ethnic services could play a crucial part in introducing Callum to more mainstream services where his alcohol and cannabis use can be monitored, and diagnosis made.

Also, without long-term and safe accommodation, Callum will remain vulnerable. Once engaged with mainstream services a housing officer should be allocated who could arrange supported housing and a support package.

Should Callum’s complaint of sexual assault be real, it must be established whether he wants to press charges. Unfortunately, because of his psychological vulnerability he could possibly be a poor witness, and this must be taken into account when going to court.

Callum desperately needs a relationship of trust with someone sympathetic to his needs. A trusting relationship must be established if there is any hope of his mental health improving in the long term.

Helen Waddell is a mental health service user