Back to the real world.


Situation: Sandra Manley is 45 and suffers
acute anxiety. Two years ago her husband of 25 years died, which
understandably increased her levels of anxiety. She lost contact
with her son, 24, when he moved to France to live with and marry
his partner, whom he met on holiday. Indeed their meeting at the
funeral was the first time mother and son had seen each other in
four years. Despite promises to keep in touch her son has again
discontinued contact – prompted in the main by the demands of his
wife and her family and because he lives abroad.

Problem: Sandra’s situation has inflamed her
anxiety to such an extent that she is unable to manage her own care
effectively. She is also uncommunicative. Pamela Fawley-Barnes, a
neighbour who is active in the local church and who attended the
funeral, has been popping in each week to see how she is, make a
sandwich and say prayers for her. Pamela has noticed that Sandra is
losing weight – and is convinced that she is not eating regularly
because of the way she eats very quickly whatever Pamela makes for
her. Pamela does not want to visit more than weekly as she finds
Sandra’s anxiety too upsetting and is uncomfortable in what – given
the untidiness and lack of cleaning – is for her an unhygienic

Practice panel Milton Keynes mental health team panel

David Glover-Wright.

Sandra’s situation is similar to many referrals received each week
by community mental health teams (CMHTs). It will not even be
considered by many teams unless the client’s GP has made the

Discussions ensue concerning why the GP has made the referral and
comments are made about the “inappropriateness” of the referral and
the need to “signpost” on to a counselling agency. This highlights
the limitations of many CMHTs. They are too busy fire-fighting and
coping with acute mental health needs and long-term chronic
problems to deal with the likes of Sandra. So the GP receives a
letter explaining that she does not fit the team’s referral
criteria and suggesting other options.

Meanwhile, Sandra is probably unaware that she has been referred to
the CMHT and continues to become anxious despite the probable
prescription of antidepressants. The tablets make her feel more
isolated and make it difficult for her to motivate herself.

Her neighbour is becoming increasingly concerned and is perhaps the
only person who really sees what is going on. But she is struggling
in isolation to respond to Sandra’s needs, hampered by her own
fears and prejudices.

Perhaps the neighbour belongs to a strong and active church
fellowship, so a regular visiting schedule could be established to
support Sandra. This might avoid her assimilation into the mental
health system. But the chances are that the church fellowship has
the same fears of mental health issues as others and will shy away
from becoming too involved.

Clearly, Sandra needs an urgent assessment. This would be best
provided by her GP with a primary mental health care worker aligned
to the GP. It cannot be ruled out that she might have an underlying
physical health problem causing her weight loss and erratic eating
habits. A plan could be for the practice worker to link up with the
local church and begin raising their awareness of mental health

Sandra could then be treated effectively by her own community
addressing her need for friendship and human contact to counter her
experience of loss.

Kathie Paice.

Sandra is isolated and appears only to be having meaningful contact
with the neighbour. She seems to be suffering anxiety and
depression. Symptoms can often be similar and one condition can
mask the other, so careful assessment is required.

She seems to have isolated herself, is uncommunicative and is
losing weight due to her poor diet. The house’s untidy state is a
further reflection of her declining self-care. However, the
situation could be falsely distorted by the neighbour’s high
standards and stereotyping.

An assessment of Sandra should focus on the following:

  • Sleeping pattern. Is she able to fall asleep at night at a
    reasonable time and is she suffering from early morning waking and
    then unable to resume her sleep?
  • Mood pattern. I would ask her to describe to me her feelings
    over the past couple of weeks and focus on the language used.
  • Posture and non-verbal communication. Is she sitting in a
    huddled position or relaxed stance? A “tight” posture might
    indicate she is uncomfortable with the situation and finds it
    difficult to make contact with herself and others. Does she engage
    in eye contact? Poor eye contact might indicate low
  • Appetite. I would ask whether she has been eating before
    feeling anxious and low, and if a change had occurred.
  • Activities. I would ask her about her levels of concentration
    and interest. Has she noticed any discernible changes? Is she able
    to concentrate on a TV programme or article in a magazine?

Sandra’s anxiety also needs addressing. She has lost both her
husband and son and her corresponding roles as wife and mother. I
would want to establish a rapport with her and would visit weekly
to start with. I would be careful not to encourage dependence on my

During my first contact I would be assessing my intervention using
the Beck’s suicidal intent scale. My overall goals would be shared
with Sandra. She needs time and space to talk about her feelings
and to feel valued. She might eventually agree to considering day
care or input from a community support worker to consolidate her

User view.   

Social isolation is the single biggest factor to affect the
quality of life of mental health service users. Whether it is the
cause or the effect of mental health problems is irrelevant; what
matters is the pain of the resulting loneliness, and that people
are helped to overcome it, writes Kay Sheldon.  Having lost her
partner of 25 years, it is no wonder that Sandra is experiencing
severe anxiety and social withdrawal. Things have got on top of her
to the extent that she is barely coping and is probably feeling
isolated and miserable. She needs someone to offer lots of
non-judgemental support and encouragement to give her life meaning
again.  In the first instance, it may be possible to encourage her
to make some contacts with the outside world. These could be low
key to start with to build her self-confidence, such as voluntary
work or an adult education class. It may be that Sandra would find
this too daunting and may benefit from some more therapeutic
help.   Her first point of contact would probably be her GP. She
may find it difficult going to the doctor to ask for help but this
should be encouraged if it seems that things are not going to
improve without help. Several options could be available through
her GP and the primary (or secondary) health care team. Ideally,
medication should be held off initially and some sort of
psychological input offered. This could take the form of, for
example, bereavement counselling, cognitive behavioural therapy,
problem-solving or anxiety management.   The most important factor
in determining the strategy should be Sandra’s preferences. This
may be quite difficult for her to decide at the beginning and it
may be that she needs medication before she can even think about
tackling her problems. Medication can certainly give you a lift or
make you feel calmer but after the initial “high” you realise that
your problems are still there. It may be at this point that Sandra
will be able to be more positive and hopeful about psychological
therapy.   Prevention and self-management are often important
aspects for mental health service users. If Sandra can also be
helped to work out her own strategies and ways of coping, she will
be more likely to have a meaningful and rewarding life. An
important aspect could lie in arranging visits to see her son in
France. She may need initial help to do this but it could enhance
the quality of her life. 

Kay Sheldon is a mental health service

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