Centres on the brink

Many people with mental health problems get a lot out of
attending a day centre. But if a person’s behaviour becomes a
problem, centre staff can find themselves relatively isolated. Mike
George talks to Christine Wray-Smith about how she faced just such
a situation.

For many people with mental health problems, day centres offer
valuable forms of social interaction and constructive activities.
Their importance is widely recognised, and efforts to improve what
they offer continue to be made. However, day centre staff can be
quite isolated, and often have to deal with very difficult types of
behaviour without always being able to obtain support from other

For while mental health professionals obviously value the role
of day centres, these centres may not always be properly integrated
into multi-agency care and support programmes, and this can cause
problems for day centre staff and clients alike. This has certainly
been the experience of Christine Wray-Smith, manager of a Richmond
Fellowship day centre, as she and her staff have tried to support
Mary Thomas (not her real name).

Thomas, who is in her thirties, was diagnosed many years ago
with bipolar affective disorder. She lives on her own and has
little or no support from wider family members, though she does
have a few friends.

She has been admitted several times into psychiatric hospitals,
both voluntarily and under Mental Health Act 1983 provisions, and
sometimes for long periods.

A few years ago she was referred by the hospital to the day
centre, as it offered a variety of group activities which, it was
thought, would benefit her. These included a women’s group and
groupwork on anger management and assertiveness. In addition, the
day centre staff and the centre’s other clients would offer her a
wider range of social interaction, as otherwise she was fairly
socially isolated.

At first, she joined in enthusiastically, but gradually became

She was increasingly anxious and depressed, and engaged in
self-destructive behaviour. She wanted to see her community
psychiatric nurse, her psychiatrist and GP more frequently. She
also asked for regular counselling, which, Wray-Smith explains,
proved impossible to organise. “We’re a listening service really,
and can only make requests of other agencies,” she says.

Her destructive and needy behaviour started to create tension
among other clients. One morning she arrived at the centre
unclothed and extremely distraught, and Wray-Smith felt she had no
alternative but to call on her GP and CPN so an immediate Mental
Health Act assessment could be made. As a result, Thomas was
admitted to hospital.

After discharge, she again returned to the day centre and, as
before, appeared to be benefiting from her involvement – but again
she gradually became upset, anxious and severely depressed. “We
were very concerned about her – she appeared to want a lot more
support than she was getting, so through consultations with her
CPN, she was offered a few weeks’ respite care in a residential
unit,” says Wray-Smith. “This clearly made her feel safer and her
mood and behaviour improved a great deal, both there and when she
attended our centre during the day. However, when it was time for
her to leave respite care she became very upset. She was screaming
and throwing things around, and whatever we tried to do at the
centre we couldn’t seem to help her.

“Eventually, I managed to take her into another room, so that
her behaviour wouldn’t be so upsetting for our other clients. She
was threatening to take her own life, and I knew her well enough to
know that she was at serious risk. But for a while I was unable to
get hold of any mental health professionals, and all I could do was
to be with her and try to prevent her carrying out her threat.

“After quite some time I managed to get her CPN and GP to come
to the centre, which immediately calmed her down. She returned to
the centre the next day, again in a distraught state, and hit a
member of staff,” she adds.

As a result of this incident, an immediate assessment was
carried out and she was compulsorily admitted to hospital again. As
before, her behaviour and mood improved while she was in hospital.
She has now been discharged, and has started to attend the day
centre again.

So Wray-Smith and her colleagues are likely to face a recurrence
of the problems they’ve already experienced. While the day centre
staff have developed a good relationship with Thomas, the centre
cannot operate a 24-hour service, so when she is not there her
anxieties, self-destructive behaviour and depression often

Wray-Smith emphasises that the day centre has offered Thomas a
high degree of security and close personal relationships, but she
adds: “It seems clear that she is falling through the net of care,
perhaps because she is thought to have relatively mild mental
health problems – though as we know, the problems can become very
serious, to the point where she is at very high risk.”

While some form of 24-hour care would meet Thomas’ needs, she
also wants to be active and reasonably independent. “It is very
frustrating for all of us, because she does have a lot of insight
into her illness, and quite understandably gets upset that it’s
stopping her getting on with her life,” says Wray-Smith.

“We at the centre can only do so much. There is a need for more
effective interventions, especially the provision of respite care
for the times when she’s most anxious. The lack of respite
facilities is a major problem for us, for her, and for some of our
other clients.”

 Arguments for risk

– Thomas has been assessed several times, and her mental health
problems, while very distressing, are not regarded as serious
enough to require her to be a long-stay hospital patient.
– She wants to live independently, and to “get on with her
– She can call on support from the day centre staff, her consultant
psychiatrist, CPN, and GP.
– The day centre offers regular, dependable personal support, and
activity aimed at improving her self-confidence and
– Thomas can stay reasonably well for periods of time, during which
she is active and outgoing.
– Her medication regime has been assessed several times.
– To some extent her anxieties, depressions and destructive
behaviour may occur because she has insight into her bipolar
affective disorder and its effects on her life. So perhaps these
episodes should be regarded as an accepted part of her

Arguments against risk

– She has been seriously suicidal and self-destructive, so is at
very high risk at times.
– These episodes appear to have occurred when she has been at the
day centre, where staff have had some difficulty in getting rapid
support from other agencies.
– She has frequently upset other vulnerable clients who attend the
day centre, and has attacked a member of staff.
– Her reaction to hospitalisation, and to her stay in the respite
residential placement, shows that she feels less anxious and
depressed when there are 24-hour
are and support services.
– Wray-Smith and her colleagues cannot themselves demand or procure
counselling or other services that Thomas wants.
– She does not have any support from her family or friends.
– Short-stay respite care in particular has clearly been of great
help to her, but there is a severe resource shortage.

Independent comment

All too often the focus of attention on risk in mental health is
narrowly directed towards risk assessment. This should not be a
stand-alone function. We need to have mechanisms in place that
offer responsive, flexible and co-ordinated actions that meet the
needs of the individual, writes Steve Morgan. This story
illustrates the dilemmas faced by mental health workers, in
particular accessibility of appropriate services, multi-agency
co-ordination and rapid responses.

Christine Wray-Smith has communicated the identified risks, only
to be let down by the responses of the wider network of care. At
the levels of national and local policy, service accessibility is
largely linked to the implementation of the integrated care
programme approach and care management process. Mary Thomas is
denied access on grounds of mild mental health problems. Yet her
periods of high vulnerability and risk may require her to play a
dangerous game of “raising the stakes” to receive further

Good quality voluntary sector agencies are often victims of the
statutory sector rules for the practical implementation of the care
programme approach. Their expertise is often relegated within an
artificial hierarchy, which ranks the perceived expertise of the
statutory sector professionals above that of the service user,
carer and voluntary sector representatives. There is a strong
argument for closer scrutiny of what multi-agency working means in

The issues of service accessibility and risk management
highlighted in this article point strongly to the need for a
targeted 24-hour crisis response service. Even with the label of
mild mental health problems, Mary Thomas still requires frequent
hospital admissions and expensive respite in supported
accommodation. Expectations of support are raised, only to be
dashed when they cannot be met long-term. Mary experiences a
roller-coaster of emotions, and Wray-Smith is left to count the
cost of flagging up unmet needs.

Steve Morgan is practice development manager (risk), Sainsbury
Centre for Mental Health.

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