Permanently engaged

People with mental health needs can prove difficult to engage
with effectively. A common root cause for this is a strong distrust
of authority. Thus simple engagement tactics such as finding
informal meeting places and so on have to combine with stronger
methods of building up trust and relationships.

Young people suffering from an episode of psychosis, which is a
loss of contact with reality, can experience disturbing thoughts,
delusions or hallucinations leaving them confused and distressed.
Escalation of anxiety in social situations, a common feature of
psychosis, provides a further obstacle to accessing support. The
quicker these symptoms can be understood and treated the greater
chance of their elimination.

Such difficulties were faced by care co-ordinator Sue Devonshire in
the case of 24-year-old Andrew Murray, who was suffering a first
episode of psychosis and hearing voices constantly and experiencing
delusional and paranoid thoughts. Indeed, the difficulties faced in
engaging with Murray were heightened because of his homelessness.
As he could not be contacted by visit, phone or letter, all contact
had to be motivated by Murray and he found it difficult turning up
to meetings on time or at all.

Early contact by Devonshire and her colleagues was very informal
because of Murray’s unwillingness to trust authority figures. “We
began by trying to secure safe and appropriate accommodation for
him,” says Devonshire. “This was a difficult and time-consuming
process. He was caught up in a cycle of mental health issues that
disrupted his accommodation and vice-versa.”

As well as sleeping rough, Murray had at times stayed at local
authority hostels. However, these stays had proved even more
traumatic as other residents, usually older, shared “an equally
chaotic lifestyle,” says Devonshire, “with drug and alcohol
misuse”.

Nonetheless, Murray would often pop into the youth service centre
as it provided a warm, non-threatening, youth-oriented environment
and, of course, other people of a similar age to meet and chat
with. The drop-in nature of the centre suited him.

Devonshire used these visits to foster trust with him. “We ensured
that he was able to obtain food, receive help with money and obtain
support and insight into his psychotic experiences,” says
Devonshire. “Our initial approach, which helped him to sort out
practical issues, increased his trust of workers and his
willingness to engage more fully. He was clearly struggling with
stuff internally but we gave him the time and space.”

One day, Devonshire found him unsure whether to finally talk about
his experiences. “So, I just said, ‘I’ll be here for the next two
hours or so. If you want to talk, I’m here’. And a little later he
knocked on my door,” she recalls. Two hours of traumatic and often
delusional thoughts and ideas followed. But he was finally
engaged.

Murray began talking more about his delusional ideas and thoughts.
Devonshire coaxed him to consider the benefits of seeing the
centre’s in-house psychiatrist. Murray, despite deep-rooted
concerns about side-effects and associated stigma, also considered
anti-psychotic medication.

“Getting to the initial meeting with the psychiatrist was no mean
feat,” says Devonshire. “At first, he would only see the
psychiatrist if he felt sufficiently unwell. The team was conscious
of treading carefully in order not to scare him off and risk losing
contact.”

But with consistent support and encouragement Murray finally began
sessions with the psychiatrist. The youth-friendly approach and
environment of the centre was pivotal in this success. Murray,
understandably, remains uncomfortable with the idea and practice of
the sessions, but does now recognise the personal benefits that
have resulted.

Things are now falling into place for Murray. “He now has a care
plan,” says Devonshire. “He is aware that this will not be an easy
transition for him. We are working on his identified goals for the
immediate and long-term future. These include finding appropriate
and meaningful training or employment and increasing his social
opportunities.”

Significantly, Murray moved into permanent accommodation -Êa
supported housing scheme, with staff on call during evenings and
weekends. This was again achieved through a patient, time-consuming
process, so indicative of the team’s approach.

“He sees this as an opportunity to put down some roots,” says
Devonshire. It could well be the anchor required to bring stability
to the chaos and turmoil that has characterised his life so
far.

Case notes

The name of the service user has been changed

Practitioner: Sue Devonshire
Field: Care co-ordinator, mental health
Location: South west England 
Client: Andrew Murray is a 24-year-old white male
who experiences delusional and paranoid thoughts accompanied by
constant voices.
Case history: Murray has a history of sleeping
rough on the streets or in parks. At points of crisis he would stay
in local authority hostels and had recently slept on a
friend’s floor, but his friend had been taking nearly all
Murray’s benefit entitlement to pay for this. His
accommodation breakdowns would often see Murray seek help from a
popular youth services centre, which offers support, information
and counselling. Workers at the centre were increasingly concerned
about Murray’s behaviour as were the mental health team, also
based in the centre. Contact was kept very informally at first as
the team did not want to scare Murray off. They realised that time
and patience were the best route to engaging Murray
effectively.
Dilemma: It was clear that Murray needed to talk
about his distressing experiences but the team knew that he had to
come to them and had to be patient.
Risk factor: Murray was clearly at risk but he
deeply distrusted people he considered to be in authority and any
attempt to engage him professionally would potentially put him at
greater risk by resuming a life back on the streets.
Outcome: Murray now has an agreed care plan and is
in appropriate supported accommodation.

Independent comment

This case illustrates the dilemma that can be faced by all
services when a young person experiences a first episode of
psychosis, writes Eric Davis. The response provided by Sue
Devonshire and her team is to be commended.
Engagement is crucial to making progress. Because practical issues
such as a place to talk to other young people, accommodation and
budgeting skills were provided, further psychological and medical
issues such as the nature of the psychosis and details of symptoms
could be addressed, and psychological therapies and medication also
considered.
However, the issues of engagement and the time required to secure
such engagement are pivotal. If for any reason, this engagement
could not have been secured, then Devonshire would be faced with a
dilemma: whether to invoke use of the Mental Health Act 1983 in the
case of serious psychological or psychiatric disturbance. If the
need for such a choice arose, hard-won trust and confidentiality
would be jeopardised.
Nevertheless, the work with Murray exemplifies a sound, creative
and youth-friendly approach that appears promising in terms of
improving the lives of young people developing first-episode
psychosis. The emphasis upon developing a service which is
responsive to the specific needs of young people with psychosis is
to be applauded.
Eric Davis is consultant clinical psychologist with the
Gloucestershire NHS Partnership Trust, and south west regional lead
for early intervention in psychosis. Visit www.iris-initiative.org.uk