Searching for a way out

Practice
panel: Bradford mental health services.

This
week’s multi-disciplinary panel considers the case of a young woman with a
psychotic illness who wants to leave hospital.

Case
study

Situation

Noor Begum (not her real name) is a 23-year-old woman from Bangladesh who has a
psychotic illness. For the past two years she has been a patient in a local
psychiatric hospital. She is separated from her husband and five-year-old son
and from her extended family in England.

Problem

The case was referred to the community mental health team in order to provide a
placement for Noor in the community. Noor came to England at the age of 16 to
live with her father and stepfamily. She developed psychotic symptoms but
returned to Bangladesh where she married and gave birth to her son. Noor and
her husband returned to England but a rapid deterioration in her mental health
led to the marriage breaking down. Her husband returned with the child to
Bangladesh. She was admitted to hospital in 1999. There are no members of her family
willing to support her. Her use and understanding of English is limited. Her
frustration at being in hospital is characterised by aggressive outbursts. Noor
wants to live in her own accommodation but hospital staff feel she requires
24-hour support in a care home. She refuses to consider this but local
supported accommodation projects are reluctant to offer her a place. Noor’s
continued hospitalisation means that her limited self-care skills are
deteriorating and her behaviour is reflecting her unhappiness. The Mental
Health Act 1983 has been used to ensure she remains in hospital.

Panel responses

Dipak
Patel
Having been in hospital for at least two years, Noor Begum has hopefully
received a full multi-disciplinary assessment of her needs. The case study does
not indicate whether she is currently on an acute ward or a specialist
rehabilitation unit. It would be unsatisfactory if she is on a busy acute ward
where her specialist needs might be overlooked and where busy staff would be
unlikely to have the time to offer individual nursing care.

In
Bradford, the local Asian Women’s Mental Health Group should be approached to
offer support to her while she is in hospital. The aim would be for them to
develop a supportive relationship with Noor and enable her to participate in
community-based activities even though she remains a hospital inpatient. This
could involve attending support groups and participating in short language
courses to enable her to improve her English language skills.

It
is said that she does not wish to move from hospital to a care home. Is there a
local unit that can offer a degree of independence within a setting that offers
24-hour support? Is there a local assertive outreach service that can provide
additional intensive support based on the "recovery" model, which
recognises that people with long-term mental health problems do have the
capacity to recover from their illness?

The
combination of a specialist mental health housing support agency and an
imaginative and intensive community support package might encourage Noor to
consider the community-based options that would be available.

Noor
has been detained, and possibly still is, under the Mental Health Act 1983.
Should all attempts fail to provide a placement that is acceptable to her then
the multi-disciplinary team should consider the use of guardianship or
supervised discharge to assess whether the law would assist in discharging her
from hospital to the community. Although the potential use of compulsion in the
community is contentious there have been positive uses of guardianship to
ensure that a reluctant individual leaves hospital and lives in an appropriate
community placement with a comprehensive and supportive care plan.

Gill
Rowe-Aslam
My initial response was that two years appears to be a long time for Noor
Begum to have spent in hospital. It is not clear why she continues to be
detained under the Mental Health Act 1983.

I
would suggest that a review of Noor’s mental health status should take place
and that efforts should be made to fully support her through any appeal or
hearing that may follow.

The
introduction of an advocate could be valuable in allowing Noor to be
represented and making sure she is fully involved in decisions about her
future.

Ideally,
this person would be able to communicate with her in her first language. It
would be important for her to feel able to express her views and to gain
information about the choices that are available to her.

Depending
on the availability of staff who can communicate directly with Noor it would be
helpful for her to have regular contact with workers who have an understanding
of her cultural and religious needs. This might help in reducing feelings of
isolation and vulnerability. It may be necessary to employ a female interpreter.
Such a regular arrangement would allow the possibility of a trusting
relationship to develop.

I
would be interested to know the extent to which Noor’s family had previously
been involved in her care. The reluctance of family members to support her
could be explored. I would consider that their position in this matter may be
influenced by lack of information about their relative’s care, and apprehension
about the level or demand that a caring role might require. Previous
involvement in her care may be a factor within this. It would be helpful to
assess their need for support and possibly introduce them to a carer agency or
consider additional resources they may require. The whole issue of her feelings
about the loss of her son would need to be addressed sensitively.

Noor
would need to be placed on the care programme approach. She would need to be
allocated a keyworker, preferably several weeks before she is due to leave
hospital, in order to build up a relationship of trust, and who would continue
to be responsible for her care once she leaves hospital.

User view

Having
been in a similar situation, I can identify with the frustration Noor is
feeling from being kept in hospital for so long and being told she won’t cope
in her own accommodation. However, I can only guess at how greatly this
frustration must be exacerbated by not being able to speak and understand
English very well. Presumably an interpreter is used from time to time for the
exchange of information but this is unlikely to be anywhere near enough. Noor
has lost her husband, child and home, not to mention her liberty and
independence. Noor needs the opportunity to talk freely with a skilled listener
in her own language so she can vent her feelings and work through her options.

After
being in hospital for so long (too long in my view) it is no wonder Noor’s
self-care skills are deteriorating. When you are kept in a mental health
hospital for any length of time you forget how to think for yourself. I think
the mental health team has a responsibility to help Noor regain her living
skills and, as Noor has expressed a desire to live in her own accommodation,
the team should aim for this. It is important for the people involved with her
care to work at establishing a positive working relationship based on honesty
and trust.

She
should be told about the reluctance of supported housing to take her on and
why. A plan of action should be agreed with (not for) her, comprised of
negotiated stages such as an appropriate rehabilitation unit or a staffed
house. Noor should be given a written copy of the plan in her own language,
which should be reviewed frequently and broken down into as many steps as is
needed.

If
Noor is willing, an advocate could help ensure Noor’s point of view is put
across effectively, again preferably one who speaks her own language or at
least has been trained in using an interpreter.

The
mental health team could also help Noor in re-establishing links with her own
cultural community, for example finding a Bangladeshi befriender or arranging
visits to a Bangladeshi social group. Noor may find it helpful to learn more
English; a volunteer could be arranged or, if Noor is up to it, attendance at a
class.

Noor
is right to feel angry and frustrated. She deserves the opportunity to live
independently and the appropriate help and support to make this possible.

Kay
Sheldon is a mental health service user.