Situation: Rosemary Jennings is 41 and lives at home with her younger brother Ronnie, 27. Rosemary believes she has a serious mental illness and should be in hospital. Despite regular hospitalisations she has only ever been diagnosed with a personality disorder. Her social worker for the past five years is extremely frustrated about his apparent inability to substantially improve matters for Rosemary. All his efforts to engage with her have failed.
Problem: Rosemary’s delusional thoughts continue and she has recently begun to neglect herself and her home. She has become very inactive preferring to lie on her sofa, believing it at times to be her hospital bed in which she is secured and unable to move. Ronnie, who is unemployed, is misusing alcohol and soft drugs. He has been taking money (mainly benefits) from Rosemary to fund his lifestyle. There is also a concern that Ronnie has been physically assaulting her but she says her facial bruises were caused by her falling out of her “hospital bed” and struggling with the male charge nurse. Rosemary has continually refused to have any home care support. The house is unhygienic – rubbish is mounting in all parts of the home and Ronnie says that he can’t stand it when she urinates and defecates on the sofa – and has to drag her to the lavatory. The stench, fear of rodents and Rosemary’s occasionally hysterical screaming has caused complaints from neighbours.
The first question to ask is why does Rosemary believe she should be in hospital? It is necessary to review her past admissions and understand the previous triggers, particularly as there don’t seem to have been any positive outcomes from her previous experiences as an inpatient.
The social worker has been involved with Rosemary for the past five years; this is a long time for one professional to hold a particularly complex case. It seems the social worker might have lost his direction and needs to take a fresh look at her needs. The social worker needs to bring Rosemary’s situation back to his team and facilitate a clinical discussion looking at the various options available.
Rosemary’s case highlights the need for effective and regular clinical supervision addressing the social worker’s feelings of frustration and inertia.
Rosemary’s behaviour appears to have changed with the recent emergence of self-neglect. This could be linked to a number of significant factors. Ronnie’s drug usage could be affecting her mental state, particularly if he is smoking cannabis within her immediate vicinity. This could cause her to become increasingly paranoid and delusional.
Ronnie’s misappropriation of her benefits could be limiting her dietary intake creating apathy and low motivation. This, in turn, could lead to greater self-neglect and cause a downward spiral in her situation.
A vulnerable adults case conference needs to be convened with a multi-disciplinary panel to determine the best way forward. It could be that Rosemary is simply expressing delusional beliefs and is genuinely sustaining injuries through falling. However, Ronnie is still exploiting her vulnerability and his behaviour needs to be challenged.
This is a difficult situation to address. It could be admission is the most appropriate action and a Mental Health Act 1983 assessment needs to be convened given issues about her capacity and ability to give informed consent. Other services need to be engaged to improve the home situation. This will only be possible if Ronnie is engaged in this process and can derive benefit from intervention, given his own mental health needs.
At first glance this situation seems desperate with few “access points”. Rosemary’s pattern of behaviour appears to be rigid and unchangeable requiring urgent intervention and probable admission to hospital. This will seem unavoidable once the pressure to “do something” reaches fever pitch. Her lack of motivation and passive behaviour makes her easy prey to her brother’s exploitative behaviour.
However, on closer analysis, there are opportunities to challenge and move the situation forward. The intensity of the situation and the social worker’s own perceived helplessness have combined to create a situation of professional inertia.
The diagnosis of “personality disorder” sounds an ominous warning to all professionals attempting to engage with Rosemary. Too often personality disorder is interpreted as “non-compliant”, “untreatable” and “manipulative”, highlighting the inflexibility of conventional mental health services, with complex underlying social issues confounding the usual tried and trusted treatment plans.
A comprehensive risk assessment is required to determine whether “home treatment” is still viable and safe to provide. Rosemary’s physical health is of paramount importance and is clearly bound up in her mental health needs.
The social worker needs to reappraise the situation and seek support and advice from colleagues. He could seek to engage Ronnie and help to promote a sense of responsibility, enabling him to appreciate the benefits of intervention for both himself and his sister. Undertaking a carer’s assessment might serve to reinforce this. A crisis intervention service could then work with Rosemary in her home and work to minimise the risks and pave the way for long-term support. A crisis intervention team could work around the clock with Rosemary and challenge some of her behavioural patterns through a deeper understanding of her needs and promotion of her self-worth.
Alternatively, a home intervention may not be able to turn the situation around. Rosemary’s admission to hospital might allow for rigorous planning to start with the goal of alternative accommodation upon discharge.
Rosemary’s situation illustrates the thorny issue of diagnosis in mental health, writes Kay Sheldon. You can’t help wondering that if Rosemary had been given a different diagnosis to “personality disorder”, whether she would have been treated differently, and maybe more successfully.
The main symptom of Rosemary’s condition is she believes she has a mental illness and this belief is considered to be caused by her having a personality disorder. Yet, for other people, “delusional” beliefs would have generated a different diagnosis such as schizophrenia or psychosis. Maybe other opinions are warranted in Rosemary’s case, preferably from a multi-disciplinary team rather that just a doctor.
Diagnosis should have no bearing on the help offered, and services should base their response on level of need or distress. If it were, Rosemary would probably merit immediate, intensive help. However, because of her “personality disorder” label, which is seen by many professionals as untreatable and at best something that can only be “managed”, Rosemary is unlikely to get a good deal from general mental health services, even generating resentment from staff as she is taking up a precious bed or valuable professional time.
I can’t see how keeping Rosemary at home with her brother can serve any benefit. Equally, the pattern of regularly admitting Rosemary to an acute ward and discharging her back to the same social situation seems unhelpful. Modern mental health services are geared up to treat an illness (usually by medication and sometimes six sessions of cognitive behavioural therapy) when it, or the person, becomes a problem (a crisis) and then to “monitor” through visits or appointments. Very little genuinely therapeutic or supportive help is available and it is rarely tailored for an individual.
Somebody needs to take the initiative with Rosemary and think more creatively about helping her. A longer term strategy built around her needs and wishes should be devised. It may be that a therapist with particular skills is recruited to work with Rosemary. Alternatively, finding a residential placement – NHS or private, or even abroad – with a breadth and depth of therapeutic input may be preferable.
Creativity and perseverance may also be required to find the necessary funding. The use of direct payments could additionally be considered.
Kay Sheldon is a mental health service user.