Is there an alternative?

Case study 
The names of the service user and her husband have been
changed

Situation:
Noreen Lewis, 59, lives with her husband, Michael, 63.
They are both retired professionals. Noreen has a diagnosis of
bipolar affective disorder (also known as manic depression). This
is a disorder characterised by extreme swings in mood, from high to
low, from depression to elation and over-activity (mania). She
acknowledges this but is very anti-medication. An aromatherapist
and herbalist, Noreen has told the community mental health team
(CMHT) and psychologist that she no longer needs their input as
they are preoccupied with conventional medication and
treatments. 

PROBLEM:
The marriage is failing and Noreen’s mental health is
deteriorating. Michael and the psychologist collude and are
convinced that the  marriage will be fine if Noreen takes her
medication. However, again she refuses and Michael requests a
Mental Health Act 1983 assessment. The CMHT and crisis resolution
team are convinced she needs hospital in-patient care and are not
prepared to look at community support options as she is
“non-compliant” with medication. Noreen is adamant she does not
want to go into hospital (having had a distressing time previously)
but will accept treatment (St John’s wort – a herbal
antidepressant) and community support if mental health services
understand her perspective. They refuse and Noreen is sectioned
under the Mental Health Act. Noreen is now presenting many
challenges in terms of after-care and support for the community
services.

Practice Panel Mental Health Team – Milton
Keynes
Steve Caffrey – team manager, community mental health team ; David
Glover-Wright, team manager, CMHT ; Kathie Price, community
psychiatric nurse, CMHT ; Jane Ross – community psychiatric
nurse

Panel responses
Steve Caffrey
Working with someone with bipolar affective disorder is widely
accepted by practitioners as a challenge. It is often stressful for
those involved. Add to this a strong family dynamic and it is
hardly surprising that practitioners and family members are
vulnerable to “collusion”, which can only damage any semblance of
trust.

The challenge now for practitioners is to establish a trusting
relationship from which to negotiate and implement an aftercare
plan that is acceptable to Noreen. It is likely she has no faith in
the multi-disciplinary team and in her husband. She feels
betrayed.

A decision about the key worker is central to an effective
aftercare plan. What role will Noreen have to choose the key
worker(s)? Good practice means having a co-worker involved, peer
supervision and strong management support. The multi-disciplinary
team needs to be focused, supportive of each other, positive and
creative. And it will need to prepare for the long haul: there is
no quick fix.

Presumably, the hospital treatment will have achieved some
stability in Noreen’s mood. In theory then, she should be well
enough to participate in aftercare plans. Any negotiation seems to
hinge on whether the medics will agree to her use of St John’s
wort. In fact, she does not need permission: it can be bought over
the counter. There have been clinical trials that support the use
of St John’s wort in the treatment of depression, but it is not a
mood stabiliser and it will be difficult to engage with Noreen if
she is unstable.

In any event, medication is only part of the answer and possibly
even a red herring in this case. Her view on powerful modern drugs
is not unreasonable and must be respected. Serious consideration
should be given to other treatments like cognitive behavioural
therapy. A collaborative, guided discovery and educational style of
cognitive behavioural therapy could be more valuable for Noreen if
she wants to take an active part in her therapy. Thought should be
given to including her husband in a therapeutic plan because there
are obvious complexities and tensions in their relationship that
will impede any progress if they are not addressed.

David Glover-Wright
Noreen’s situation is by no means unique. There are many
people who are reluctant to engage with conventional mental health
services, having justifiable fears about the side effects of
powerful “antipsychotic” medications. They are also concerned that
they will not be regarded as individuals with their own unique
understanding of their mental health needs.

Contemporary mental health services are still struggling to break
the circle of fear that exists for many people faced with the
prospect of ongoing contact with psychiatry. Recent research
undertaken by Mind has highlighted that people’s experiences of
in-patient care are often negative. 

Patients often feel they gain more support and help from their
fellow in-patients than they do from professionals. Noreen might
have seen her psychiatrist weekly in large formal team meetings.
She might have had little opportunity to share her concerns and
anxieties with nurses who could have been concentrating on the more
disturbed and “difficult to manage” patients. An acute in-patient
ward can be a frightening place, offering limited opportunities to
address underlying mental health needs. 

The assessment team probably believed there was little alternative
and felt constrained by the risks had Noreen not been admitted. Few
areas in the country have viable alternatives to acute in-patient
care. Noreen might be an ideal candidate for a non-statutory
therapeutic environment where her wishes to receive alternative
means of treatment can be respected. Professionals should
acknowledge that Noreen has insight into her mental health needs
and a willingness to find solutions to her problems and should move
away from reactive, short-term fixes. 

The challenge now will be for professionals to help Noreen regain
confidence in the mental health services by showing a willingness
to meet her halfway. Her community key worker will need to start
regular visits while Noreen is an in-patient and begin listening to
her views on how she wants to move things forward. 

It seems a seismic shift is needed to enable Noreen to occupy a
central position in her treatment rather than being consigned to
the periphery. A service user advocate might assist Noreen in the
long process of regaining control over her life.

User view 
The services need to make a much greater effort to understand
Noreen’s perspective, writes Kay
Sheldon.

Health and social care provision is supposedly based on individual
needs and choice. The professionals involved in Noreen’s care have
the opportunity to make this aspiration a reality. Noreen is clear
about what she does and doesn’t want and this should form the basis
of her care package. 

Most mental health interventions, including medication, have a weak
evidence base. Much of the research has produced results that are
either inconclusive or cannot be generalised. 

Noreen’s desire to use herbalism and aromatherapy should not be
viewed as less valid than the typical medication-and-psychology
combination that mainstream mental health services are
offering.

Psychiatric medication works for some people but for many others it
is an unacceptable option, usually because of the horrendous short-
and long-term effects it has on a person’s psychological and
physical health. If doctors and nurses were made to sample the
medication they prescribe and administer, they would think twice
about prescribing it. Antipsychotic drugs and mood stabilisers in
particular have nasty side effects, including lethargy, shaking,
restlessness, weight gain and blood disorders.

Noreen is being honest and open with the mental health services,
something the mental health professionals should value and build
on. Noreen needs a psychiatrist and community mental health team
which is willing to think beyond their professional
constraints. 

Advice should be sought from experts in herbalism and aromatherapy,
so the options can be discussed with Noreen. Her husband should be
fully involved and is likely to have to overcome his expectation of
services, just as the professionals will. Collusion between
Noreen’s husband and members of her care team is
unacceptable.

A range of strategies should be explored with Noreen and her
husband which could be a combination of alternative or
complementary ones alongside more conventional ones, such as
self-management, relaxation and identifying “triggers” and early
warning signs. 

Direct payments should used if necessary to fund any services that
are not available from the health or social care services. The
professionals involved in Noreen’s care should approach it with a
view to making it work, rather than believing it will fail. 

Kay Sheldon is a mental health service user