More than mental health

Case study

The name of the service user has been changed.

Situation: Kelly Boyce is an 18-year-old single parent mother. She has a daughter, Leah, who is five months old. Kelly has spent most of her teenage years in care. She was physically and emotionally abused as a child and on many occasions was left unsupervised for long periods. On other occasions family members looked after her. Kelly was eight when she was first referredto local social services.

Problem: Kelly has been turning up regularly at the hospital A&E since the birth of her child. She has taken a number of overdoses and has received treatment after self-harming episodes. Her GP has diagnosed depression and has prescribed her anti-depressants. The GP has minimal contact with Kelly. The social services department’s Options for Independent Living team is involved in monitoring her progress but appears not to be too concerned for Leah. Kelly attends a family centre with Leah each week, and concerns have been expressed about the lack of bonding between parent and child. Kelly has recently become involved in a violent and abusive relationship and there are concerns that her boyfriend is her pimp. A&E staff have recently become seriously concerned about Kelly’s mental state and her ability to care for Leah.

Kelly has been talking about suicide and sees “no way out” from her current situation.

Panel responses

Oonagh Moriarty
In the case of Kelly and Leah good multi-agency working is crucial. It is important that all the agencies involved with mother and baby communicate effectively and meet regularly. For example, those professionals working in child care agencies might need support with mental health issues and the other way around. Indeed, this is exactly the type of co-operation that the government has in its thinking with the proposal for children’s trusts following the recommendations of the Laming Inquiry into the death of Victoria Climbi’.

There is a danger of labelling or making assumptions because Kelly has been in care and experienced abuse. However, this does not mean that she cannot parent or is automatically mentally ill. It is possible that Kelly is suffering from post-natal depression and so this needs exploring with health professionals.

The focus of any assessment of the state of Kelly’s mental health should be whether she is a risk to herself or others. These cases are especially complex. On top of the question of risk, one has to ask whether Kelly’s mental health problems are such that her ability to parent is flawed in some way, even though they may not be so acute as to impair her functioning as an adult.

This situation should be approached from a position of support. Kelly’s self-esteem is low and any support should take this into account. She needs individual counselling and perhaps this could include life story work.

The family centre appears to be a positive factor in her life and this should be built upon. Kelly would benefit not just from help with parenting but with practical support. Reluctantly, I would consider respite care as childminding for Leah may benefit mother and baby. This would give Kelly time for herself. A family group conference could be effective. Despite Kelly’s experience of her own parents, there may be extended family members who could offer support.

It would be damaging for Leah to become looked after, whereas a multi-agency support plan with input from extended family might have more chance of a positive outcome for mother and baby.

Julie Bootle
There are several issues raised by this scenario, including the role of primary care and the ability of the various services involved in this young woman’s life to communicate effectively. She clearly demonstrates signs of distress, but these are being dealt with piecemeal rather than as a whole. This appears to be contributing to Kelly’s increasing distress and resulting in her upping the ante with talk of suicide.

There needs to be effective communication between the GP, the Options for Independent Living team, the family centre and a representative from A&E to ensure all services are aware of the whole situation and take a consistent line with this young woman. However, as there is a young child in a potentially threatening situation, any risk assessment must focus on the needs of the child as well as the mother.

It may be helpful to explore the extended family to see whether there is anyone who could offer Kelly informal support, as Kelly herself was cared for by other members of the family before being taken into care.

While it seems likely that Kelly is experiencing post-natal depression, which is affecting her ability to parent her daughter as well as look after herself, the prescription of anti-depressants alone is unlikely to resolve the situation.

It also appears that Kelly has a number of unresolved issues about her past which are influencing her ability to care for and bond with her child. This may also have contributed to her entering into an abusive relationship, which appears to be repeating experiences from her childhood.

Individual counselling may help her to explore her feelings and responses. It is important to understand why she is self-harming and what this action achieves for her that she cannot get from other means, and help her work towards a different response.

This is a complex and charged situation. It would be easy to label this young woman as mentally ill and unable to parent due to her own life experiences. It is important that all parties involved in the care of this family communicate effectively with each other and with Kelly to minimise the risks to mother and the child. With the right help there is no reason why this family should break down.

User view

The help that Kelly is receiving is not really meeting her needs, as it is only geared up to her as a lone parent, writes Kay Sheldon. I feel she needs help from specialist services to sort out her mental health difficulties before she can benefit from the other support she is having.  

Kelly is feeling increasingly desperate, to the extent of contemplating suicide. She is probably suffering from post-natal depression which, together with her traumatic background, makes her and her daughter vulnerable. There doesn’t seem to be immediate concern for the baby’s well-being. 

A holistic approach is crucially important for Kelly. If she is willing, then a referral to a specialist community mental health team would probably be beneficial. A member of staff from the family centre or the Options for Independent Living team with whom Kelly has a good relationship could suggest this to Kelly and accompany her to the initial appointment if necessary. As well as sorting out any medication, it may be helpful for Kelly to have some sessions with a psychologist or therapist. There are many issues that could be troubling her – her background of neglect and abuse, her current relationship and her being a young single mother. In particular, the issues of Kelly self-harming and taking overdoses should be explored with her in an non-judgemental way. 

It will be also be important for Kelly to maintain links with her support network. Contact with specialist mental health services can also have a negative impact on a person’s life. It is easy, once you have been received into the mental health system, to lose touch with normal life: becoming very dependent on one or two people and only attending mental health day services. Every effort should be made to enable Kelly to make her own decisions and to make sure that any help offered is relevant to her situation. There may be other community or non-statutory organisations that could provide Kelly with more support with regard to, for example, her age, background or interests. 

It may be that Kelly needs extra help in developing the skills needed to look after a child. This should be facilitated in a positive manner as Kelly’s confidence is likely to be fragile. Another option is whether Kelly would like to arrange some child care so she can return to education or get a job. Having another focus in her life could help her cope better with being a single mother. 

Kay Sheldon is a mental health service user.