No show means no help

Services fail to engage with a young man who has substance and mental health problems. But are they accessible enough?

Case study
The name of the service user has been changed

Situation: Kevin Jackson, 26, has a history of drug and alcohol use. Six years ago, he was diagnosed with clinical depression. However, he did not engage fully with services as he was, and remains, nervous about discussing his problems. Consequently, he has drifted in and out of treatment. He has attended a residential alcohol detox service four times but completed only one stay. He struggled with abstention. He has also been convicted three times of possession of Class A drugs and has served a short jail term. His attempts at employment usually founder on his criminal record.

Problem: In the past year he has become increasingly suspicious and has prolonged bouts of paranoia. He had problems with his benefits payments and accrued rent arrears. Now he has absconded from his flat and is moving between squatting and staying with friends – crashing on floors wherever he can. He is considered a low priority by housing services as, technically, he is not homeless. He is trying to control his alcohol intake and has volunteered for drug treatment but struggled to get out of bed in time for appointments and soon relapsed – again being unable to give them up. All his friends use drugs and alcohol. A drop-in centre he uses for free coffee persuaded him to be referred to the community mental health team – but he failed to make the appointment.

Practice Panel – Milton Keynes mental health team

Panel responses
David Glover-Wright
This case scenario is a perfect example of the service leading the client and not the other way around. Kevin has probably had negative experiences of clinically focused services that have been unable to connect with him. He needs to know that people see him as someone worth helping and he needs encouragement to put his life story together. This will need time but will help him to begin appreciating the level of risk in his situation. Eventually, he might begin making connections with previous situations and see how he can deal more positively with future scenarios.

Kevin has tried to make changes in the past, but is going to be put off if he perceives he cannot work at his pace or there are unrealistic expectations. Kevin is prepared for a referral to be made to the community mental health team (CMHT). These sometimes struggle with people with a dual diagnosis and it is important to avoid the “batting back and forth” between specialist substance misuse and mainstream mental health services.

Kevin has some insight in to his mental health needs. But having no fixed abode, possibly no income and leading a chaotic lifestyle make it difficult for him to begin dealing with his problems.
A CMHT worker needs to arrange to meet Kevin at the drop-in centre rather than send an appointment letter. Certainly this is a model adopted by assertive outreach teams when working with people unable or unfamiliar with the structures and expectations of our services. Caution is needed not to alienate Kevin by creating a negative association.

Kevin seems to have few positive influences in his life, only friends who misuse drugs and alcohol. He needs to take back some responsibility for his situation but will not be able to do this until he sees he can aim for worthwhile and reachable goals. These need to be decided with him.

Without this approach, it is possible his mental health will deteriorate and his behaviour “breaks through”. This will then be an issue for those around him and take him down the statutory route to assessment under the Mental Health Act 1983.

This response was written with Carol Murray, social work student at Milton Keynes Community Drug and Alcohol Centre

Jane Ross
Kevin needs some long-term, gradual intervention. There are no easy solutions to his situation. His lifestyle is entrenched and may well continue on its path before any significant therapeutic intervention can take place.

Kevin seems unable to fit in with mainstream society and the social inclusion argument would suggest he needs help to assume a meaningful and positive role in society.

Kevin needs to see that a service is prepared to go the extra mile with him. It’s no good offering appointments for somewhere on the other side of town with all that might represent to him. This will lead only to a sense of failure and the service’s view that he does not want to engage.

In Milton Keynes we have a first-tier service which offers a drop-in and outreach provision for people like Kevin. The service would need to link up with our specialist dual diagnosis team and gain support and advice about Kevin’s mental health needs. These cannot be separated out from his lifestyle and persistent substance misuse problems.

Kevin’s situation could be managed most effectively in a team where several workers can establish a rapport with him and share the responsibility of working with the stresses generated. This might not suit Kevin and he might respond best to an individual approach. Good peer group support, supervision and line management are crucial for working with people in Kevin’s position.

The team will need to be flexible and able to respond to his lifestyle. Specialist agencies such as Revolving Doors can assist in supporting this type of service and good practice ideas will be needed when working with him.

It may be that the only way to reach Kevin is through the Mental Health Act 1983. This might seem draconian but taking him out of his situation and placing him somewhere where he can learn to acknowledge and appreciate his needs could benefit him.

The danger of this action is that he might be alienated further from services attempting to work with him and he will be drawn back to those that give him meaning and identity. There needs to be a way to acknowledge Kevin’s social identity and culture which lies outside the boundaries of most of our services.

User view
It is unlikely that the mental health services would follow up Kevin if he failed to show up for appointments, the theory being that you have to want help before you can benefit from it. This is a great shame, writes Kay Sheldon.

This thinking is flawed because there can be many reasons why someone doesn’t engage with the service, not least – as is cited in Kevin’s case – feeling uncomfortable with divulging your problems to a stranger. Other reasons include thinking you are not worth bothering about and the belief that nothing can help.

Since Kevin is not a serious danger to anyone – if he misses an appointment the most he is likely to receive is a letter asking him to rearrange it, which he is unlikely to do.

There should be attempts made to build a trusting relationship with Kevin. This should be low-key and in the early stages perhaps just meeting for coffee. But it should be persevered with as the potential gains for Kevin – and for the wider community – are huge.

Kevin seems to have a chaotic lifestyle and it is difficult to imagine that he can cope with his mental health difficulties when his housing and financial arrangements are unstable.

Helping sort out these aspects of his life is something practical the services could focus on which may be less threatening than other forms of help. In turn, the help provided could also help to nurture a trusting relationship.

It is known that there is a link between depression and drug and alcohol use, although the cause and effect is unclear. You can become trapped in a vicious circle of using alcohol or drugs to cope with your symptoms which can give immediate relief but in the longer term make the symptoms worse.

Kevin has already tried to address his problems and this shows he has motivation for this. Once a relationship has been established, the services could engage Kevin in a plan to help him understand and improve his mental health. This could be psychological or other therapy, supportive counselling, education or medication. The important thing is for it to be a true partnership with Kevin and has to be at Kevin’s pace.

Kevin has also shown a desire to find a job which could be a powerful motivator. Various return-to-work schemes could be explored with him. A mentor may also be someone that he could benefit from to develop his self-confidence.

Kay Sheldon is a mental health service user