PRACTITIONER: Nick Perry, social worker.
FIELD: Mental health.
LOCATION: Westminster, London.
CLIENT: Shirley Souza, 63, is a black African who came to England in the 1960s with her family. She has long been estranged from her husband, and has no known contact with her children. She has a schizophrenic illness and alcohol problems.
CASE HISTORY: Souza has been known to psychiatric services for about 30 years. Since 1992 she has held an assured tenancy in a hostel managed by a homelessness charity. In 2002 she started a relationship with Michael McGough, now 43, who has a history of alcohol problems and antisocial behaviour. The relationship had begun to cause difficulties at the hostel, not only with McGough’s aggressive behaviour when intoxicated but because Souza was in breach of her tenancy which does not permit guests to stay the night. In late 2004, McGough was taken into custody for a public order offence. Souza’s mental health was fragile and despite the apparent volatility of the relationship, without the emotional support from McGough, her mental health deteriorated. The hostel requested an assessment under the Mental Health Act 1983.
DILEMMA: Because of her illness, Souza cannot always understand what may be in her best interests, and this has lengthened her compulsory admission to hospital.
RISK FACTOR: Although wishing to continue her relationship with McGough, there are concerns over violence, exploitation and homelessness should they live together.
OUTCOME: Work is continuing to secure Souza’s return to the community.
Our state of mind is often directed by the quality of our relationships. On a simple level, positive relationships can breed confidence and happiness; whereas negative ones and relationship breakdown can provoke mental health problems for many.
But then things are never always that simple. For some, any form of relationship – even one where others suspect exploitative and abusive behaviour – can still generate positive outcomes; and have traumatic effects if it breaks down.
This, on one level, appears to be the dilemma facing involvement with Shirley Souza, 63, a woman with schizophrenic illness living in an assured tenancy in a hostel for the homeless. Through a street drinking network she took up with Michael McGough, 43, who has a history of alcohol problems and antisocial and aggressive behaviour.
However, McGough would stay over in breach of Souza’s tenancy and invariably become drunk and aggressive. “Because of her long-term mental health problems Shirley has the capacity to make decisions about some things but not others,” says social worker Nick Perry who took up the case in October 2004. “She couldn’t understand why Michael wasn’t able to stay with her in the flat.”
He adds: “However, she has been very clear about wanting to continue the relationship and despite our concerns about the potential risks that Michael poses to her – an adult protection meeting in 2003 proved inconclusive about possible physical abuse and financial exploitation – she is adamant that she wants him to be part of her life.”
Perry had to decide whether to work with them as a couple or as individuals. “They wanted to be together so it was pointless trying to develop alternative plans because they were likely to be sabotaged. So we worked with them both, recognising Michael as her partner,” he says.
However, during this time McGough breached an antisocial behaviour order and was sent to prison. “With the loss of Michael’s emotional support, Shirley’s mental health deteriorated considerably and, in December 2004, she was admitted to hospital initially under section two (for compulsory assessment) of the Mental Health Act 1983,” says Perry. However, this was later converted to a section three, for compulsory treatment.
She has remained in hospital ever since. “This has partly been because of the difficulties in providing the right plan for her mainly around appropriate housing,” explains Perry.
Unfortunately, there was no specialist accommodation available to meet the needs of this vulnerable couple. Perry says: “We developed a plan, with multi-disciplinary agreement, where general needs housing can be allocated so that they can live together but with different care packages going in to meet their separate needs.”
However, says Perry, the joint accommodation was contingent on two factors: “On leaving hospital Shirley would go into more sheltered accommodation at the hostel (rather than her own flat) so she could be closer to staff and have her daily living skills monitored; and for Michael to find accommodation on his own and address positively his alcohol issues.”
However, another problem arose. Despite initially agreeing with the plan, Shirley changed her mind. “She said she didn’t want to move from the flat and that became intractable,” says Perry. “In some senses, the reasoning had a psychotic flavour but she was unable to get hold of the arguments, balance them and think what was in her best interests.
“My sense is that the flat is a symbol of stability for her, somewhere she feels safe as she has been there a long time. And yet she wants a place that she can share with Michael, which cannot be her flat – so there are contradictions to work through.”
Souza’s adherence to her flat remains the stumbling block. The plan now is to apply for a guardianship order (which in this case requires the approval of two doctors and an approved social worker) which will enable the local authority to direct where she lives and thus relinquish the tenancy.
“There’s no guarantee that Shirley will comply,” says Perry. “One of the reasons we are pursuing it is that she has been very compliant with medication and has been willing to listen to the voice of medical authority. The hope is that, with her psychiatrist involved, the guardianship might be acceptable to her. She may then see that a move from her flat is in her best interests and is designed to help her have a shared space with Michael.”
Arguments for risk
Arguments against risk
It can be exhausting trying to understand, unpick and help manage the complexities that affect people’s lives. Working towards solutions can be emotionally draining and test the relationships between people involved, writes Tom Dodd.
In his book Risk, published in 1996, John Adams says: “Remember that everyone else is seeking to manage risk, too” – and this includes Souza. There are times when she may not recognise risk, but there are other times when she can be more engaged in how to manage.
Adams goes on to say: “Safety interventions redistribute the burden of risk, not reduce it.” The distribution of accountability, through a multidisciplinary and multi-agency approach, is what could be supportive to workers such as Perry.
The Joseph Rowntree Foundation (Living with Risk, 2004) asks the question: “How much is the desire to get a service user in supported housing fulfilling their needs, or those of professionals for them to be somewhere ‘safe’?” Perry is helping retain a focus on Souza’s wishes and needs, although this is likely to mean more effort and more negotiation.
Professionals may be challenged by working with McGough and Souza, but Perry is right in doing what he can to sustain the relationship and build on those small positive changes. It’s essential to work with people close to Souza in the longer term, to build their resilience, tolerance and understanding of her experiences. Perry is working well not to add to the stigma that invariably surrounds this case.
Tom Dodd is national lead for community teams, National Institute for Mental Health in England